Neighborhood Bike Works

Youth Application & Waiver I’m interested in joining: [ ] Earn-A-Bike [ ] Ride Club [ ] Summer Camp [ ] Other

Parents and Guardians: To request enrollment in a program, please complete this application with your child and return it to NBW’s office at 3943 Lancaster Ave, Monday-Friday 10AM-6PM, (215) 386-0316, or photograph and email it to: [email protected]

First Name:

Last Name:

Date of Birth:

Current Grade Level:

School: Cell Phone:

YOUTH INFO

Email:

NBW has permission to contact youth by: [ ] Email [ ] Text [ ] Phone Call I identify my gender as: [ ] Male/Boy/Man [ ] Female/Girl/Woman [ ] Transgender [ ] Non-binary I identify my race/ethnicity as (check all that apply): [ ] Black or African American [ ] White or Caucasian [ ] Hispanic or Latino [ ] American Indian or Alaska Native [ ] Native Hawaiian or Other Pacific Islander [ ] Asian [ ] Other:

PARENT / GUARDIAN INFO

First Name:

Last Name:

Address:

City:

ZIP

Primary Phone: Secondary Phone: [ ] Cell [ ] Home [ ] Work [ ] Cell [ ] Home [ ] Work Email: Please help us gather info for our funders so NBW after-school programs can remain free to youth:

My family is eligible to receive some form of public assistance such as food stamps, cash assistance, or low income heating support. [ ] YES [ ] NO Page 1/3

LIABILITY WAIVER The undersigned hereby recognizes that bicycling and bicycle repair are not absolutely safe, and that accidents can and do occur, including injuries that may be serious and permanent, despite all reasonable care. In consideration of the services to be rendered to the undersigned by Neighborhood Bike Works Inc. (referred to herein as “Neighborhood Bike Works), the undersigned for themselves and their heirs, personal representatives and assignees, expressly releases, waives and covenants not to sue Neighborhood Bike Works, its shareholders, members, officers, directors, partners, employees, agents, volunteers, successors and assigns (“Released Parties”), with respect to any liability for injury, death, property loss, claim(s), demand(s), cause(s) of action, damage(s), loss or expense, including court costs and reasonable attorneys’ fees, of any kind or nature which may arise out of, result from or is related to bicycle instruction, bicycle training, bicycle repairs, bicycle mechanics, bicycle safety instruction, bicycle rides, bicycle tours, bicycle competition, or any other indoor or outdoor activity or field trip conducted under the supervision of Neighborhood Bike Works, including claims for liability caused in whole or in part by the negligence of any of the Released Parties. The undersigned further agrees that if they, or anyone on their behalf makes a claim for liability against the Released Parties, they will indemnify, defend and hold harmless each of the Released Parties from any such liability that may be incurred as a result of such claim. By signing this form, the undersigned, being a person of at least eighteen (18) years of age acting on behalf of the following Participant as Self, Parent, or Guardian, I acknowledge my understanding of the foregoing, that I am signing this form voluntarily, and that I give Neighborhood Bike Works and any of their employees, volunteers, successors, assigns, trustees, officers, and agents the power to authorize medical care for the participant. I also acknowledge that the participant should properly use a bicycle helmet whenever riding a bicycle.

Parent/Guardian Signature:

Date:

HEALTH & SAFETY Is the participant allergic to anything? [ ] YES [ ] NO If so, please list: NBW Staff will administer Benadryl if the participant is experiencing an allergic reaction. Please check here if you do not give permission: [ ] Does the participant have and use an asthma inhaler on a daily basis? [ ] YES [ ] NO Please inform NBW Staff on the first day of the program and ensure the participant carries their inhaler with them at all times. Is the participant taking any medication? [ ] YES [ ] NO If so, please list: NBW is not responsible for administering medications. Please assure that the participant is able to take their own medication. Inform NBW staff if the participant needs supervision. May the participant wade in water while supervised by NBW staff? [ ] YES [ ] NO Is the participant able to ride a bike, and for 20 minutes at a reasonable pace without rest? [ ] YES [ ] NO [ ] YES [ ] NO Does the participant have any medical/mobility/mental health concerns we should know about in order to best serve their needs? [ ] YES [ ] NO If so, please list: Page 2/3

EMERGENCY CONTACT Who can NBW contact in case we cannot reach the Parent/Guardian already listed? First Name:

Last Name:

Relationship to Participant:

Phone:

TRANSPORTATION May the participant leave NBW activities by themselves? [ ] YES [ ] NO If not, list everyone the participant can leave with, and their relationship to the participant:

May the participant leave NBW activities on a bicycle by themselves? [ ] YES [ ] NO May the participant take SEPTA with NBW for activities? [ ] YES [ ] NO Does the participant have a weekly transit pass provided by their school? [ ] YES [ ] NO NBW is able to provide tokens to program participants so they can safely return home. Will the participant need a token at the end of NBW classes and activities? [ ] YES [ ] NO

WORD ON THE STREET? How did your family hear about NBW? (check all that apply): [ ] From a NBW Graduate named:

[ ] NBW Website

[ ] Family [ ] Friend [ ] Flyer in the neighborhood [ ] Facebook [ ] Twitter [ ] Instagram [ ] Participant’s school [ ] Another after-school program [ ] Other:

MEDIA & FEEDBACK RELEASE In consideration of the opportunity to participate in the programs offered by Neighborhood Bike Works I, hereby give permission to Neighborhood Bike Works, its employees, affiliates, representatives, contractors, agents and members of the media to interview, audiotape, photograph, videotape, film, or capture by any other electronic means my/my child’s image and speech, and, within its absolute discretion, to release, disseminate, or use, in any manner it sees fit including publications and web pages, the resulting images and testimonials and any other information contained therein for the purpose of promoting the objective of Neighborhood Bike Works. This includes the release of feedback and information as collected through surveys and evaluations for the purpose of program evaluation. Please check here if you do not give permission: [ ]

WHAT’S NEXT... Thank you for completing this application! Before our instructors call you to discuss enrollment, please consider your transportation plan to and from our programs, and follow us on social media! Facebook: @NBWPhilly Twitter: @NeighBikeWorks Instagram: neighborhoodbikeworks Page 3/3