Biking Buddies Bike Clinic Registration Form

Biking Buddies Bike Clinic Registration Form
WHAT IS BIKING BUDDIES: A four class series taught by a licensed physical therapist that supports parents/caregivers in teaching their children how safely and effectively learn to ride a two-wheeled pedal bike.

WHEN: Saturdays - July 9th, 16th, 23rd, and 30th from 9:30am - 10:30am

WHERE: Rear parking lot of Premier Pediatric Therapy Source's clinic location
6715 Little River Turnpike, Annandale, VA 22003

PURPOSE: To support your child’s learning in a fun group atmosphere with individualized attention to facilitate successful bike riding. A physical therapist will provide individualized support based on your child’s needs to facilitate personalized instruction for successful bike riding.

WHO can participate: This class is geared towards children ages 4-8 years
- All abilities are welcome
- One parent/caregiver is expected to participate during each class
Parents/caregivers and children will learn how to:
- Properly adjust a bike to fit the child for optimal learning
- Size and fit a helmet for optimal safety while riding
- Support their child’s learning in a fun group atmosphere with individualized attention to facilitate success
- Ride a bike!
What to bring:
- Your child's bike – balance bike or pedal bike without training wheels (we will have tools to make adjustments as needed to support your rider)
- A snug helmet (we will help with adjusting straps as needed for safe wear)
- Comfortable supportive footwear (no open toe shoes or sandals) for all participants
- Water
- A positive attitude and readiness for fun!
What to expect:
- Parking: You may park on side parking lot of the building at Premier Pediatric Therapy Source
- Each class will begin with safety instructions to ensure everyone is able to have fun and remains safe. All participants are expected to follow safety instructions throughout the Biking Buddies Bike Riding Camp. Camp registration, waiver form, and payment must be completed prior to participation
- All classes build upon skills learned in previous classes. If you need to miss a class for any reason, we will do our best to work with you so that you and your child are prepared for the next class.
- Parents/Accompanying adults are expected to remain with their child for the full duration of each class
- Shade may be limited on a sunny day so consider wearing a hat and/or sunscreen
- Bathrooms will not be available on site so please plan accordingly
Child’s Name *
Date of Birth *

Month Day Year
Date
Special Considerations *
What do you hope your child gains from this class? *
Adult Participant First and Last Name *
Relationship to Child *
Address *
Email *
example@example.com
Phone *
First and Last Name Emergency Contact #1 *
Relationship *
Phone *
Alternate Phone
First and Last name Emergency Contact #2
Relationship
Phone
Alternate Phone

Biking Buddies Bike Riding Clinic Participant Waiver
Waiver & Release of Liability: PLEASE READ CAREFULLY BEFORE ACCEPTING PARTICIPATION. THIS IS A RELEASE OF LIABILITY & WAIVER OF CERTAIN LEGAL RIGHTS.
I blanks the parent/legal guardian of blank, voluntarily release and hold harmless PREMIER PEDIATRIC THERAPY SOURCE, INC.“PPTS” and it's volunteers from any and all claims, demands and causes of action whatsoever, arising out of or related to any and all claims of loss, damage, or injury, that may be sustained by the participants and/or the undersigned, while engaging in the BIKING BUDDIES Bike Riding Clinic (“BIKING BUDDIES).
I agree to abide by and follow all safety rules presented during the BIKING BUDDIES classes and willingly and knowingly assume for myself and the minor participant, all risk of physical injury or emotional distress which may occur during any class, and I agree to hold PPTS employees and it's volunteers harmless from any and all liability arising from participation. I understand, agree, and acknowledge that there are risks inherent to bike riding activities and that these activities may be of a hazardous nature.

With full understanding of the facts, I state that to the best of my knowledge I, or my child listed above, has no medical, physical, or emotional health conditions, which would hinder or prevent participation in the BIKING BUDDIES Bike Riding Clinic. I also understand that this form must be signed by the adult participant and/or parent/legal guardian of a participant under 18 years of age prior to participating in BIKING BUDDIES classes.

I HAVE CAREFULLY READ ALL OF THE ABOVE INFORMATION. I ACCEPT AND ACKNOWLEDGE IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND SIGNIFICANCE. I UNDERSTAND THAT THE INFORMATION HEREIN WILL GOVERN MY RELATIONSHIP AND THE RELATIONSHIP OF ANY PARTICIPANTS WITH PREMIER PEDIATRIC THERAPY SOURCE. MY ACCEPTANCE HERE SUPERSEDES ANY OTHER AGREEMENT, WRITTEN OR ORAL, THAT MAY HAVE BEEN PRESENTED TO ME WITH RESPECT TO MY RELATIONSHIP WITH PREMIER PEDIATRIC THERAPY SOURCE.
First and Last Name of Child Participant *
Date of Birth *

Month Day Year
Date
Parent/Legal Guardian Name *
Parent/Legal Guardian Signature *

Clear
Date *

Month Day Year
Date
Adult Participant Name(if different from above)
Adult Participant Name Signature

Clear
Date

Month Day Year
Date

Biking Buddies Bike Riding Clinic Photo Release Consent
I understand that photographs or videos may occasionally be taken during the Biking Buddies Bike Riding Clinic and may be used for Premier Pediatric Therapy Source (PPTS) marketing purposes to promote the Biking Buddies Bike Riding Clinic or other services provided by PPTS, through print material, the practice website, social media, promotions, video and/or other advertising.

I understand that I can choose to not have my child photographed and it will not prevent my child from participating in the Biking Buddies Bike Riding Clinic.

I further understand I can revoke my authorization for the above uses at any time by sending a written notice to Premier Pediatric Therapy Source: 6715 Little River Turnpike, Suite 200, Annandale, VA 22003.

Please initial your preference and sign below.
I grant permission and consent for my child to be photographed during Biking Buddies and release all rights related to said photographs.
I request that photographs NOT be taken of my child during Biking Buddies.
Name of Parent/Legal Guardian *

First Name Last Name
Child Participant Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date

Payment Form

Biking Buddies Saturdays - July 9,16,23,30

$ 110.00

Total

$ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

To download a copy of the registration, waiver and photo release forms click the "Preview PDF" button or download after submission of this form.

Thank You!
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Biking Buddies Bike Clinic Registration Form

Biking Buddies Bike Riding Clinic Participant Waiver

Biking Buddies Bike Riding Clinic Photo Release Consent

Payment Form