ReCyclery Mountain Bike Club:         Participant Emergency Information
Thank you for your interest in the ReCyclery's MTB Club! This is a FUN club and ALL levels are welcomed. Riders will progress over the course of each session, sharpen their skills along the way, make friends, and build a riding community.  


This packet must be completed before your rider joins us.


The ReCyclery is a non-profit organization and relies heavily on community donations. We aim to reduce barriers to bike ownership, sustainable transportation, and recreational riding.

Follow us on
Instagram (https://www.instagram.com/ptrecyclery/) & Facebook (https://www.facebook.com/ptrecyclery).
Important information will be sent to Primary Emergency Contact's email on file.

For questions or concerns regarding your rider or this form, please contact Programs@ptrecyclery.org.
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Email *
Rider Name *
Rider Pronouns
Primary Emergency Contact Name *
Primary Emergency Contact Relationship *
Primary Emergency Contact Phone Number *
Primary Contact Email *
Primary Contact Address *
Secondary Emergency Contact *
Secondary Emergency Contact Relationship *
Secondary Emergency Contact Phone Number *
Do you have insurance? *
Does your insurance company require preauthorization?
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Insurance Company Name:
Policy Number:
Physician Name:
Physician Phone Number:
Please address any medical concerns or allergies of the rider/participant here: *
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