Earn-A-Bike Permission Form
Freewheelin’ Community Bikes’ Earn-a-Bike program allows a youngster to earn a bike by learning how to care for that bike and ride it safely. The process takes 6 - 8 two to three hour sessions. While the shop is basically a safe place, there are tools and working parts in a bike shop. And at some point your child might want to be part of our riding program. While we take every precaution, give instruction, and require helmets to be worn, there is still some risk. For that reason, we ask that you sign the release form and give us information in the unlikely event that an emergency should arise.
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Part 1 - Participant Information
All information on this form is confidential. Much of it is required by our funders. Incomplete registrations will not be accepted.
Child's First Name: *
Child's Last Name: *
Email Address: *
Age: *
Birthdate: *
MM
/
DD
/
YYYY
Race / Ethnicity: *
Gender: *
Last Grade Completed: *
School: *
Number of children in same household: *
Does your child qualify for Free or Reduced lunch? *
Does your child qualify for CCDF? *
Is your child a 21st Century Scholar? *
Does your child have any of the following disabilites? *
Check all that apply
Required
Part 2 - Parent/Guardian Info:
Parent/Guardian First Name: *
Last Name: *
Relationship to Child: *
Street Address: *
Zip: *
Best Phone Number: *
Email Address: *
Check all times your child can attend: *
Required
Check the BEST method by which we can reliably get News to you: *
Required
Part 3 - Emergency Contact Information
Emergency Contact Name: *
Relationship to child: *
Emergency Contact Number: *
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