2023 Ride for a Child Application
Thank you for your interest in the 2023 Ride for a Child program. Please fill out the questionnaire below. After submitting the questionnaire you should receive an email from darby@pedalthecause.org with more information and next steps.
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Email *
Child Information
Name (First & Last) *
Birthdate *
Diagnosis *
Hobbies and Interest *
Favorite Celebrity, Band, Sports Teams, Character *
Briefly tell your child's story- you may touch upon details such as when was the child diagnosed, how this circumstance has impacted your family, how your family and child dealt with the circumstance, and what the future holds for your child. *
Briefly describe your experience with Siteman Kids at St. Louis Children's Hospital and why you would like to participate in Pedal the Cause's Ride for a Child program? *
Would you be interested in sharing your story in an interview? *
Parent/ Family Information
Parent/ Parents First & Last Names *
Number of siblings *
Names and ages of siblings
Phone number *
Email Address *
Home Address *
Facebook, caringbridge, or website page (if applicable)
Please list the best way for your team to communicate with you (phone, email, text, facebook) *
Ideally, how often would you like to receive communication from your RFC team
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Please describe if your child has any food allergies or physical limitations.
Child's T-Shirt Size- All sizes are unisex *
Siblings T-Shirt Size
Parent(s) T-Shirt Size *
Pedal the Cause Publicity Waiver
Participant understands that photographs, videos, recordings or voice likeness may be taken in connection with Pedal the Cause and irrevocably consents to such. Participant further grants permission to Pedal the Cause and its beneficiaries to publish, in any form, any photographs, videos, recordings or voice likeness of Participant participating in the Pedal the Cause and related Ride for a Child events. Participant further agrees that Participant is not entitled to any payment for any such and waives any right to inspect or approve the use of the photographs, videos, recordings or voice likeness, and acknowledges and agrees that the rights granted to this Publicity Waiver are without compensation of any kind.
By signing this form, I am agreeing to this waiver *
Name of Participating Child Printed *
Participant Parent/Legal Guardian Name Signed *
Date *
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