Check one for each
SIGNATURE BELOW REQUIRED
In case of emergency, I hereby authorize and give permission to any physician, hospital, health care provider, or other medical personell selected by the staff of Bike Works to provide prompt medical treatment and arrange necessary related transportation for the participant. I agree that once the participant is in the care of medical personell or a medical facility, Bike Works shall have no further responsibility for the participant and I agree to pay all costs associated with such medical care and transportation. This completed form will be photocopied for the files of Bike Works.
The health history on this form is correct and not falsified to the best of our knowledge. I agree to allow Bike Works staff to dispense medications to the participant.