“Join us for a ride in the park.”
STOKER’S REGISTRATION & WAIVER FORM
(Please print clearly)
First Name: / Last Name:Street Address: / City/Prov./Postal:
Home Phone: ( ) / Cell/Work: ( )
Home E-mail:______/ Work E-mail:______
Height: __ Ft.__ in. Weight: ___ lb.
AGE GROUP: (Please complete, info needed for grants)
16 – 19:__ 20-24:__ 25 - 64:__ 65 +:__ / Which shed would you prefer to cycle from?
CNIB Shed:__ East Shed:____ Ferry Docks____
(1929 Bayview Ave.) (Victoria Park Subway Statiion) (BaySt. & Queens Quay)
South Shed:____ West Shed:____
(Cavell & Royal York) (Burnhamthorpe & The West Mall)
Have you ridden a tandem before?
Yes______No_____ / Emergency only, next of Kin: (mandatory, please complete)
Name:______
Can you volunteer for the club? Yes__ No__
Any special skills that you can share? (mechanic, writing…) Yes ___ No ___ / Relationship:______
Phone: ( )______
Any health issues that we need to know about that we should know for any future outings or events. (i.e.: Epilepsy, Diabetes, Asthma, Heart, etc.) / NO____ YES____
Explain:______
TRAILBLAZERS Hotline: (416) 760-2700.
Please mail cheque ($50)
To: TRAILBLAZERS, c/o Lynda Spinney, #611-340 Mill Rd., ETOBICOKE, ON M9C 1Y8 / Administrative Use Only:
Date:______Amount: $50.00
Method: (Circle) Cash:__ Chq. #_____
Membership:_____ or Blaze-a-Thon: _____
WAIVER AND RELEASE OF LIABILITY
I, ______, (Please print your name)
The undersigned, wishing to participate in the activities of TRAILBLAZERS Tandem Cycling Club, affirm to be in general good health, capable of the required effort, and hereby accept at my own personal risk any hazards that may occur. I hereby release TRAILBLAZERS Tandem Cycling Club, its directors, officers, servants, agents and trip organizers from any liability whatsoever for loss, damage or injury (including death) howsoever caused, which may result from my participation in the TRAILBLAZERS Tandem Cycling Club, and I declare that this release is binding upon me, my heirs, executors, administrators and assigns. I, the undersigned have read this release clause and agree that my participation in the activities of TRAILBLAZERS Tandem Cycling Club is entirely at my own risk. I agree to wear an approved helmet on all rides.
Further, full permission is hereby given to use any photographs or movies of said person taken when cycling with the TRAILBLAZERS Tandem Cycling Club.
It is further understood and agreed that a Braille reference copy of this document is available; otherwise the print copy has been read to or by all members.
Signature: ______Date: ______
Signature of Guardian: ______Date: ______
(If stoker is under 18 years of age)
Witness: ______Date: ______
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IMPORTANT: Please, original signatures are required for our Waiver form. Any questions, please call (416) 456-7117
Please mail your $50 Cheque to: TRAILBLAZERS, c/o: Lynda Spinney, #611-340 Mill Rd. ETOBICOKE, ON M9C 1Y8
“We are a recreational cycling club with a twist. We give people who have LIMITED or NO vision
______the opportunity to cycle with sighted volunteers on our tandems (bicycles built for two).”______
Registered Charity #86786 4753 RR 0001