Park County Youth Cycling Application This information will be used only for the youth cycling program and will not PARK COUNTY YOUTH CYCLING Wyoming

be shared with anyone outside of the youth cycling program. Filling out this application packet does not guarantee entry to the program. You must be in middle school or high school to apply.

BASIC INFORMATION Name:

Age:

Address:

City:

Phone Number:

Grade (7 or higher): State:

Zip:

Is texting enabled on this phone?

Yes |

No

Email Address:

EMERGENCY CONTACT Contact’s Name:

Relationship:

Phone Number:

Email:

(“mother”, “brother”, etc)

ADDITIONAL EMERGENCY CONTACT (OPTIONAL) Contact’s Name:

Relationship:

Phone Number:

Email:

(“mother”, “brother”, etc)

HEALTH DISCLOSURE Do you take any medications which could affect your ability to ride safely? Do you have any medical conditions which could affect your riding skills?

Yes | Yes |

No No

Details: Today’s Date:

Signature

Mail this application along with the CAN/PCYC Eligibility Criteria, Coach/Sponsor PO Box 41 Recommendation, and Cyclist Pledge to: Cody, WY 82414

Questions?

Call Coach Noesner 272-1323 Call Deb White 899-4372 Call Tiffany Manion 899-3535

PCYC Eligibility Criteria Road Cycling requires a specific set of skills to perform safely. Each applicant PARK COUNTY YOUTH CYCLING Wyoming

will be evaluated to see if they have the skills and or ability to learn. The coaches have been trained and have experience recognizing what skills each applicant needs to successfully ride a bicycle safely in traffic. The following areas will be observed and will be used in the coach’s evaluation.

ANSWER THESE QUESTIONS HONESTLY How many hours a week do you exercise? What is your favorite type of exercise? Do you know how to ride a bike?

No |

Yes > How often?

Do your parents or siblings ride bicycles?

No |

Yes > How often?

Do you participate in any other sports?

No |

Yes >

Are you a CAN Member?

No |

Yes

Do you drink water when you are active?

No |

Yes

Do you always do your homework/chores?

No |

Yes

WHY DO YOU WANT TO JOIN THE PARK COUNTY YOUTH CYCLING PROGRAM?

PARK COUNTY YOUTH CYCLING

PCYC Cyclist’s Pledge Joining the Park County Youth Cycling team requires perseverance and PARK COUNTY YOUTH CYCLING Wyoming

dedication. If you would like to be considered for membership on the team, please read and agree to this entire pledge.

THE PARK COUNTY YOUTH CYCLING PLEDGE your name here I, , pledge to commit to the Park County Youth Cycling Program for two years and agree to all of the following criteria: I will attend all team practices. If I have a legitimate reason to miss a practice (illness, family emergency), I will let my coaches know in advance. I understand that if I do not meet the minimum of 75% of the practices in the first year and agree to ride in a cycling charity event, I will lose my place on the team. I pledge to make safety my highest priority. I pledge to tell my coaches if I am not feeling well or have not eaten or hydrated myself properly. I pledge to come properly prepared to each ride, including wearing the appropriate clothing, sun glasses, helmet, shoes, gloves and bringing sufficient hydration and snacks as needed. I pledge to be kind and respect others at all times. I pledge that I will pay attention to, and take direction cheerfully from my coaches.

Signature

Date

Parent Signature

Date

PARK COUNTY YOUTH CYCLING

Park County Youth Cycling Waiver We take safety very seriously, but there is no way to guarantee that PARK COUNTY YOUTH CYCLING Wyoming

cyclists will never be involved in an accident or equipment failure. You must understand and accept all risks and associated liabilities in order to participate in our cycling team.

WAIVER AND RELEASE OF LIABILITY - READ BEFORE SIGNING In consideration of being allowed to participate in any way in the Park County Youth Cycling program, its related events and activities, I 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 Company immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Park County Pedalers, Park County Youth Cycling, their officers, coaches, 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. Participant’s Signature

Age

Date

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE This is to certify that I, as parent/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.

Parent’s Signature

Printed Name

Date