Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Shift *

Mornings 7:30 AM - 12:45 PM

Afternoons 12:45 PM - 4:45 PM

All Day 7:45 AM - 4:30 PM

Emergency Contact Phone *

(###)

###

####

Will you attend the mandatory meeting on Friday, June 28th? *

Yes

No

Do you have a valid CPR/First Aid card? *

Yes

No

Photographic Release *

I/We hereby give consent to NW Disability Support Bike First! to photograph our child/self to educate others about the programs and services offered by NW Disability Support. Among the uses contemplated are the illustration of articles in newsletters, in profiles that contributors receive, in brochures, to illustrate service discussed on the website, in displays at community fairs, to publicize local programs, making professional presentations, conducting research on teaching techniques and equipment used at the clinic, and to publicize the equipment and teaching methods used. In giving approval, I/we understand it is without consideration of compensation of any kind, and NW Disability Support is released from any claims or liability. If wider use is contemplated, NW Disability Support will get separate approval.

YES, I/We give consent

Medical Release *

In the event that an emergency requiring medical or surgical care or treatment should arise while attending Bike First!, and I/We ARE NOT PRESENT TO MAKE MEDICAL DECISIONS, I/we give consent for the Bike First! staff to select and designate nurses, physicians, emergency medical staff (EMS), and surgeons to furnish such medical and/or surgical care as in the judgment of a physician and/or surgeon holding a physician’s certificate issued by the Board of Medical Examiners of the State of Oregon may be needful and proper. I/We absolve NW Disability Support, and nurses, physicians, EMS personnel, and surgeons selected and designated by them, from any and all liability for their acts rendered in good faith.

YES, I/We give consent

Personal Property *

I/We recognize that NW Disability Support cannot accept responsibility for our personal property. To help eliminate losses, please tag name inside equipment, clothes or other personal items.

YES, I/We accept

Signature *

By checking the "I Accept" box, you are signing this registration form electronically ("e-signature"). You agree your e-signature is the legal equivalent of your manual signature on this registration form, as if actually signed by you in writing.

I ACCEPT