Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone

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Permission *

I hereby grant permission for my child to participate in the RVA Light Resource Ride Bike-A-Thon. I will accompany my child on the ride, and I will take full responsibility for their conduct and safety during the event.

Accident Waiver and Release of Liability *

I acknowledge that this athletic event carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers. I hereby assume all of the risks of participating and/or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. I certify that my child is physically fit, has sufficiently prepared for participation in the event and has not been advised otherwise by a qualified medical person. I acknowledge that this Accident Waiver and Release of Liability form will be used by the event holders, sponsors and organizers, in which my child may participate and that it will govern my actions and responsibilities at said events. In consideration of permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my child's death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to my child including traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: RVA Light, Inc. Their directors, officers, employees, volunteers, representatives, and agents, the even holders, event sponsors, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of my child's participation in this event, whether caused by the negligence of releases or otherwise. I hereby consent for my child to receive medical treatment that may be deemed advisable in the event of injury, accident, and/or illness during this event. I understand that at this event or related activities, my child may be photographed. I agree to allow my child's photo, video or film, likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assigns. The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I hereby certify that I have read this document; and, I understand it’s content. I agree to the Accident Waiver and Release of Liability statement above.

Electronic Signature: *

I agree and understand that electronic signatures are the legal equivalent of my manual/handwritten signature. I further agree my electronic signature on this document is as valid as if I signed the document in writing.

First Name

Last Name