Please make your donation of $15 for the Family ride/picnic: www.archildrens.org/GearsforEarsDonation

 

GEARS 4 EARS

CHILD WAIVER AND RELEASE FORM

 

With respect to the GEARS 4 EARS Bike Ride (the “Event”) with the Arkansas Children’s Hospital (“ACH”), I hereby acknowledge and grant my child(ren) __________________________________

[list name(s)] who is/are under the age of 18 permission to participate in the Event.

 

Further I understand, acknowledge and consent as follows:

 

1.     I understand the risks associated with my child(ren)’s participation in this event  include, but are not limited to: falls, contact with other participants, the effects of weather, including high heat and/or humidity, traffic and the conditions of the road.

 

2.     If my child(ren), does not follow the rules of the Event he/she/they may be removed from the Event.

 

3.     My child(ren) may receive medical treatment which may be deemed advisable in the event of injury or illness during the Event.

 

4.     ACH and other Sponsors may use my child(ren)’s name(s) and any photographs of my child(ren) that are made during the course of this event.

 

5.     My child(ren) is/are physically capable of participating in this event, that my child’s bicycle and any other equipment used to participate in the event are in working condition, that my child will observe all applicable traffic and event rules, wear a helmet and act in a safe and prudent manner while participating in the event.

 

6.  I understand that an adult must accompany all participants under the age of 18 at all times and I have approved

     the adult ___________________________ (list name) to serve in that capacity for my child(ren).

 

I hereby assume all risks and responsibilities for my child(ren)’s participation and waive, release and discharge Arkansas Children’s Hospital Foundation, Gears 4 Ears and other sponsors of this event, their officers, directors, employees and agents, for any harm, loss, personal injury, or death resulting from, arising out of, or in connections with my participation in this event.  

In case of emergency, please contact _______________________ at _____________________.

 

I CERTIFY THAT I HAVE READ THIS WAIVER AND RELEASE AND UNDERSTAND ITS SIGNIFICANCE.

 

Date: _____________________ Signature:_________________________________________

Parent or guardian’s signature