FLYRS Push Bike Summer Camp Registration 2019

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July 8-12 at 9:30am-10:30am

Participant Name *

Participant Age on July 8, 2019 *

Other:

Parent Name *

Parent Phone Number *

Parent E-mail *

Street Address *

City *

Zip Code *

Other Parent or Alternate Adult Contact Name *

Other Parent or Alternate Adult Contact Phone Number *

Any allergies, health conditions, or other issues we should know about regarding the participant? *

I give permission for my child to be photographed and/or video-recorded during FLYRS sessions, and for those artifacts to be used for either instructional or promotional purposes. *

Yes

FLYRS Push Bike Summer Camp is $75 per child. Your child’s spot will be reserved as soon as you submit (1) this completed online registration form, and (2) payment. Preferred payment method is through an app called VENMO (@FLYRS), which has no fees if you use your bank account or debit card. Alternatively, you can send a check to: FLYRS 5135 N Agave Trl Flagstaff, AZ 86001 *

I have read and understand the payment options.

In consideration of being allowed to participate in any way in the FLYRS program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the FLYRS leader; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Flagstaff Youth Riders, Inc. (FLYRS), FLYRS coaches and volunteers, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. This is to certify that I, as parent/legal guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. *

I have read the waiver and release of liability, and I fully agree to its terms.

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