Kids Building Bikes Registration Step 1 of 4 25% Student InfoStudent's Name* First Last Student's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student's Birthday (mm/dd/yyyy)* MM slash DD slash YYYY Student's Grade* What school they attend:* Student's Height (for bicycle sizing purposes):* What lessons, knowledge, and skills do you hope your child will take away from participating in our Kids Building Bikes program?*Does your child own a bicycle?* Yes No Does your child know how to ride a bicycle? (If not, that’s ok!)* Yes No Ethnicity* Is there anything else we need to know about how best to accommodate your child’s needs?*Would you like to apply for a scholarship to reduce your out of pocket cost for the program? Yes No Does your child benefit from the Free and Reduced Lunch program? Yes No Is your family enrolled in the SNAP program? Yes No What is the household income? $0-10,000 $10,000-30,000 $30,000-$50,000 $50,000-$70,000 $70,000-$100,000 $100,000+ How many people does this income support? How did you hear about us?* Kids Building Bikes Parent AgreementParent/Guardian Name* First Last Parent/Guardian Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian Phone Number*Parent/Guardian Email Address* What is the best way to contact you?* Phone Text Email Will you be the parent/guardian that is responsible for making sure your child gets to class sessions?* Yes No If there are any other adults authorized to pick your child up, please provide contact information below: First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail If the student lives within walking distance of our Building Bikes Lab, do you give them to permission to walk to and from class?* Yes No Do you or another adult family member own a bicycle?* Yes No If yes, would you be interested in participating in a family bicycle ride lead by a Nine13sports staff member? Yes No What time of day is best for us to call you (5-10 minute) to discuss and understand specific needs, goals, or skills you or your child may have?* 10am-12pm 1pm-3pm 4pm-6pm Emergency Contact Information:Name* First Last Phone*Relationship to child:* Kids Building Bikes & Nine13sports Code of ConductKids Building Bikes and Nine13sports are committed to providing a safe, caring and inclusive learning and working environment by promoting respect, responsible citizenship and academic excellence. A positive learning climate exists for learning when all participants in the programs feel safe, comfortable and accepted. Nine13sports staff members agree to demonstrate these standards of behavior when working with your child. On the first day of class behavior expectations will be presented to all participants and a signature obtained showing they have received a copy of the code of conduct. The Standards of Behavior outlined apply to all Kids Building Bikes & Nine13sports participants, including students, parents and guardians, school staff, volunteers and visitors when participating in any offered programs or training.Parent/Guardian AgreementI agree to support Nine13sports staff in holding my child accountable for the following individual behaviors:* • Demonstrate honesty and integrity. • Give best effort and have a positive mindset. • No inappropriate, profane or discriminatory language or behavior towards other participants and Nine13sports Staff Members. I agree to support Nine13sports staff in holding my child accountable for the following group behaviors:* • Respect the rights of others and treat one another with dignity and respect at all times, regardless of economic status, race or ethnicity, religion, sexual orientation, gender identity, age or ability. • Show proper care and regard for Kids Building Bikes and Nine13sports property and the property of others. • No fighting or horse play. I agree to support Nine13sports staff in holding my child accountable for adhering to the following class policies:* • Turn off all cell phones, music devices, and remove head phones during class. • No leaving the Bike Lab (scheduled breaks will occur). • No eating or drinking during class. • No tools or material will be removed from the class. • Close toed shoes are required – no flips flops or sandals or safety reasons. I will make sure my child is in on time and present for their scheduled classes* YesI understand that if my child misses more than one class, they will not receive a bicycle and will be dismissed from that session with the ability to enroll in another full session at a later date.* Yes Kids Building Bikes WaiverAs parent/guardian of the above-named child, give him/her permission to participate in the activities of the Kids Building Bikes Program and Nine13sports, including activities which take place at the location of Kids Building Bikes trailer and also any and all bicycle excursions. Activities at the shop include bike assembling, bike maintenance, riding bikes on community trails, using tools to work on their own bikes and help organizing parts at the shop. I release Kids Building Bikes and Nine13sports and its representatives from any liability in the event of an accident en route, during, or returning from an activity, and any accident resulting from riding a bicycle. My child will assemble and ride a bike from the Kids Building Bikes program. I understand the risk of riding a bicycle, and release the Kids Building Bikes program, Nine13sports and its representatives from any associated liability. I also authorize Nine13sports to obtain any emergency medical attention that may be required during my child’s participation in Kids Building Bikes and Nine13sports activities. I grant to Kids Building Bikes and Nine13sports, its representatives, volunteers, and employees the right to take photographs of my child in connection with the Kids Building Bikes and Nine13sports activities. I authorize Kids Building Bikes and Nine13sports to copyright, use photos and videos in print and/or electronically for use in marketing promotions and social media purposes. I understand I may opt out of the photo release portion of this agreement by emailing kidsbuildingbikes@nine13sports.org with the Subject Line “Media Release Opt-Out” with the name of my child. My name as entered below on this digital form also indicates that I have received a copy of the Kids Building Bikes & Nine13sports Code of Conduct and I will review this with the participant/child. E-signature* Date* MM slash DD slash YYYY Special Medical NeedsAre there any specific or special medical needs that we should be aware of for your child? Please list them below along with any information that could be helpful.CAPTCHA Δ
