Instructions: Make a copy of the registration form and waiver.
Complete the form and fax it back to us at (714) 990-2448.
BICYCLE PATROL COURSE
Dates of Course: ___________________________________
Name (as you would like it to appear on your certificate of completion: _________________________________________
Mailing Address: ___________________________________
Questionnaire (To be completed by each student)
Bicycle Make & Model (e.g., S&W Tactical):_____________________________
Helmet Make & Model (only ANSI/SNELL/CPSC rated helmets are authorized. Please check the sticker inside the helmet for safety rating:________________________
Riding Skill Level (sefl-assessment) - Please check one
_____ Beginner (basic bike riding experience)
_____ Recreational rider (1 - 10 miles per week)
_____ Intermediate (11 - 30 miles per week)
_____ Advanced (Over 30 miles per week)
_____ Racing experience(Competitive/Team rider)
Pre-Existing Injuries: ______________________________________________________________
WARNING: This Bicycle Patrol Course will require some strenuous physical activity; participants must be in excellent physical condition. Students must possess good basic bicycle riding skills prior to attending this course (e.g., balance, braking, shifting gears, basic dismounting from bike, etc.). This course is not designed to teach an individual who has never ridden a bicycle how to ride one. The Instructors have the authority to exclude students from the course who do not pass a minimum riding skills evaluation on day one of the course. Due to the seriousness of this subject matter, it is imperative that all students act in a professional, attentive manner. Students who are disruptive, unsafe, and/or inattentive may be asked to leave this riding course.
WAIVER AND RELEASE FROM LIABILITY
· In consideration of your acceptance of my enrollment in the Bicycle Patrol Training Course, I hereby waive, release and forever discharge any and all claims for damages for death, personal injury or property damage which I may have, or which may hereafter occur to me as a result of my participation in said class. This release is intended to discharge in advance Bicycle Patrol Outfitters LLC, the instructors, Michael R. Flynn and Jeffrey D. Hutchison, contract entities, and any involved municipality or other public entity and their owners, officers, employees, agents, representatives, successors and assigns from any and all claims or actions of any kind for personal injuries and/or property damage which I may cause or sustain during the class or during my travel to or from the class, and I agree to pay any and all costs including attorney's fees that may be incurred by the above entities as a result of any such claim. INITIAL______
· I attest and verify that I am in good health and that I am physically fit for this course. INITIAL______
Note: If you have been assigned to this training course by your agency, company or organization, you should be covered by Worker’s Compensation. Please check with your employer to determine your medical insurance coverage in case of injury.
· I further understand that serious accidents occasionally occur while riding a bicycle, and that participants in rides occasionally sustain mortal or serious personal injuries, and/or property damage, as a consequence thereof. Knowing the risks of bicycle riding, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who through negligence or carelessness might otherwise be liable to me (or to my heirs or assigns) for damages. INITIAL______
· I shall notify the instructors and my employer of any injuries, pre-existing medical conditions and/or other restrictions that may affect my ability to safely and effectively participate in any portion of the bicycle training course. I understand that I may be required to provide evidence of medical fitness for training if the instructor(s) have doubts as to my ability to participate and/or perform any technique(s) safely. INITIAL______
· Due to the strenuous nature of bicycle training, I understand that I will be expected to be in good physical condition. Any company, agency or other private/public entity sending personnel to this training course shall screen their personnel for any potential physical condition(s) and/or limitations that could preclude the student from participating in this physically demanding course. INITIAL______
· I understand that a hard shell bicycle helmet must be worn at all times while participating in the riding skill portions of this course. I agree to properly fit the helmet to my head prior to riding any bicycle in this class. I understand that my bicycle helmet must meet the minimum U.S. safety standards per ANSI, SNELL foundation, CPSC and/or any of the other industry recognized helmet safety certification. INITIAL______
I HAVE READ AND VOLUNTARILY SIGNED THIS RELEASE, WAIVER AND INDEMNIFICATION FORM. I UNDERSTAND THAT ALL PARAGRAPHS MUST BE INITIALED. THIS WAIVER AND RELEASE FROM LIABILITY MUST BE SIGNED AND RETURNED BEFORE PARTICIPATION IS ALLOWED IN THIS TRAINING COURSE.
Participant's Signature Date