Guardian Signature (photography release)(Required)

Scholarship
To apply for a scholarship please email Shelby@kinetickidstx.org

Payment
To request a payment by phone please email Suzy@kinetickidstx.org

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Step 1 of 8

Rider/Family Information

First Name(Required)

Last Name(Required)

Rider Gender(Required)

Rider Height (in inches)(Required)

Rider Weight(Required)

Rider Inseam(Required)

inches from floor while wearing sneaker

Rider T-Shirt Size (please indicate youth or adult)(Required)

Parent/Guardian First Name(Required)

Parent/Guardian Last Name(Required)

Parent/Guardian E-Mail(Required)

Parent/Guardian Phone(Required)

Parent/Guardian Cell Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Rider Liability Release

Rider Name(Required)

By signing, I hereby expressly acknowledge that bicycling, like many sports such as swimming, golf, soccer, and gymnastics involves movement and physical activity, and that injury or mishap are possibilities in spite of all reasonable safeguards and precautions taken. Further, I hereby expressly acknowledge that photographs and/or videos of the above rider may be taken by parties outside the control of Shine in connection with participating in bike camp. I acknowledge that Shine has limited or no control over such activities of third parties and has no control over any editing and/or use of such photos and/or video footage. As the parent/guardian of the above rider, I accept such risks as reasonable and proper, and agree to hold harmless the officers, principals, staff and volunteers of Kinetic Kids, Inc., iCan Shine, Inc., and Rainbow Trainers, Inc. should injury or mishap occur in this regard.

I understand that data collected from this program will be used to help the camp operate effectively relative to appropriate progressions, bike sizing and behavior management. I acknowledge that I may be contacted in the future for follow up information pertaining to rider progress, status or for other requests to support the future development and success of the program.

Parent/Guardian Signature(Required)

I give permission for the above rider to be photographed and/or videotaped in print or electronic media by Shine or Kinetic Kids, Inc. or third parties acting on behalf of Shine or Kinetic Kids, Inc. I acknowledge and agree that photographs and videos may be edited and used in whole or in part as desired for the purpose, which may be produced, duplicated, distributed and used for informational, promotional or other public purposes. I understand that photographs and video are not my property and there will be no compensation to me. I understand and authorize the use in writing or otherwise the name or identity of the above rider.

Parent/Guardian Signature (photography release)(Required)

Bike Camp

Rider/Family Information

Disability Information

Health Information

Session

Rider Information

Rider Liability Release

Rider/Family Information

Disability Information

Health Information

Session

Rider Information

Rider Liability Release

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