Bike Riding Sign Up

Thank you for your interest in bike riding lessons provided by one of our licensed physical therapists.

Upon completetion of the form, we will reach out to you to gather more information and get you scheduled.

Lessons are $180/session.

Name of Child*

First NameLast Name

Date of Birth of Child*

Date

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Pertinant Medical and Therapy History

Name of Guardian*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

1. Authorization: I, the undersigned parent/guardian, authorize Little Feet Therapy to take and use photographs and/or video recordings of my child for marketing, promotional, and educational purposes, including but not limited to: Social media platforms (e.g., Instagram, Facebook), Website and digital content, and Printed materials (e.g., brochures, flyers )2. Usage & Rights: I understand that these images may be edited, copied, distributed, and used in promotional materials without additional compensation to me or my child. I acknowledge that Little Feet Therapy will use them responsibly and professionally.3. Revocation of Consent: I understand that I may revoke this consent at any time by providing written notice to Little Feet Therapy. However, I acknowledge that materials already published may remain publicly accessible.

YesNoYes, but no faces please

1. Acknowledgment of Risk I, the undersigned parent/guardian, understand that bike riding involves inherent risks, including but not limited to falls, collisions, and injuries. I acknowledge that my child is voluntarily participating in this lesson with the guidance of a licensed physical therapist.

2. Release of Liability I, on behalf of my child, myself, and my heirs, hereby release, discharge, and hold harmless Little Feet Therapy, its instructors, employees, and representatives from any and all claims, liabilities, or damages arising from or related to my child’s participation in bike riding lessons, except in cases of gross negligence or willful misconduct.

3. Safety Agreement I understand that I am responsible for providing a properly sized and functional bicycle for my child. I acknowledge that safety gear, including helmets, will be provided or required. I agree to ensure my child follows all safety instructions given by the instructor.

4. Emergency Medical Treatment In the event of an injury, I authorize Little Feet Therapy and its staff to obtain medical treatment for my child if necessary. I understand that I am responsible for any medical expenses incurred.

5. Agreement and Signature By signing below, I acknowledge that I have read and understood this release form, and I voluntarily agree to its terms.

By signing below, I acknowledge that I have read and understood this release form and voluntarily agree to its terms.

Signature of Guardian*

Bike Riding Lesson Sign Up