Participant Consent Form for selected participants
- I have read the information presented in the information letter about a study being conducted by Professor S. Keshav of the School of Computer Science at the University of Waterloo. I have had the opportunity to ask any questions related to this study, to receive satisfactory answers to my questions, and any additional details I wanted. I am aware that I may withdraw from the study without penalty at any time by advising the researchers of this decision.
- This project has been reviewed by, and received ethics clearance through a University of Waterloo Research Ethics Committee. I was informed that if I have any comments or concerns resulting from my participation in this study, I might contact the Director, Office of Research Ethics at 519-888-4567 ext. 36005.
- I understand that by signing this consent form, I am not waiving any legal rights or releasing the investigator(s) or the University of Waterloo from any of their legal and professional responsibilities, except as they specifically relate to my participation in the cycling activities associated with the study as described in the Participant Waiver and Release of Liability, which I understand and agree to sign as a condition of participating in this study.
☐ I am at least 18 years old
☐ I agree to always wear a helmet when operating the e-bike
☐ I anticipate residing in the KW region and retaining a connection with the University of Waterloo for the next three years
☐ I promise to undergo a training session on safe e-bike use
With full knowledge of all foregoing, I agree, of my own free will, to participate in this study.
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Printed Name of Participant Signature of Participant
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Dated at Waterloo, Ontario Witnessed
Participant Waiver and Release of Liability
- I am aware that while participating in this study, certain risks and dangers may occur that are associated with cycling activity, including, but not limited to physical exertion that may be strenuous at times, andother hazards to myself and others associated with my cycling on routes and at dates and times of my own choosing. I understand that the University of Waterloo is not able to ensure my safety or the safety of others from such risks and dangers.
- I acknowledge that the University of Waterloo does not carry any insurance coverage that would be available to me or to any third party in the event of death, injury, or loss or damage to property caused by my cycling activity associated with this study, and that if I wish to have such insurance coverage it is my responsibility to acquire it.
- I acknowledge that I understand what is required concerning medical, health, wellness, safety, and legal considerations for the cycling activity associated with this study.
- I represent and warrant that I have no medical condition that would prevent my participation in the study.
- I acknowledge that there is a need for me to act in a responsible manner at all times while cycling and that for my personal safety and the safety of others, I should follow the safe biking guidelines that have been provided to me.
- I agree to assume full responsibility for any risks, injuries or damage that I might incur or cause to others as a result of the cycling activity associated with this study.
- I knowingly, voluntarily and expressly waive, release and forever discharge the University of Waterloo, its governors, officers, employees, students and agents from and against any and all claims, actions, demands, liabilities, damages and expenses that I may have resulting from or arising in connection with or otherwise related to my participation in cycling activity associated with this study.
With full knowledge of all foregoing, I agree, of my own free will, to participate in this study.
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Printed Name of Participant Signature of Participant
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Dated at Waterloo, Ontario Witnessed