Rider Registration Form

I Can Shine Winnipeg

July 28
th
- August 1
st

East St Paul Arena
Cost $150

We are pleased to offer this bike program to people with disabilities and look forward to working
with you and your family member to learn to ride a two-wheel bicycle independently.
Requirements for Participation (Rider must meet all of below criteria):
Minimum of 8 years of age Able to sidestep to both sides
Have a disability Minimum inseam of 2!
Able to walk without assistive
device
Ma"imum weight 22 lbs.
Willing and able to wear a
properly fitted bike helmet
Able to attend camp all # days
***All fields are required. Registration will not be accepted if this form is incomplete.***
Personal Information
$articipant %irst &ame' (((((((((((((((()ast &ame'((((((((((((((((((((((
*ender' (((((((((( +ate of ,irth'(((((((((((((((((((((((((
$arent-*uardian %irst &ame' (((((((((((((()ast &ame'((((((((((((((((((((((
.mail Address' (((((((((((((((((((((((((((((((((((((((((

Home $hone' / 0 Work $hone' / 0 1ell $hone/ 0
$referred method of contact' Home Work 1ell
2treet'((((((((((((((((((((((((((((((1ity' ((((((((((((((((((((((

$rovince- 2tate'((((((((((((((((((((( $ostal 1ode' ((((((((((((((((((((
.mergency 1ontact' &ame' (((((((((((((((((((((( $hone' (((((((((((((((((
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+ocument 3 445A
Phsical Information
Height' inches Weight' lbs. 6nseam' inches /measure from floor while
rider is wearing sneakers0
7 shirt si8e' circle 9outh or Adult and 2mall Medium )arge :) 2:)
Additional shirts /;2< please indicate si8e/s0 and =uantities0' ((((((((((((((

!isabilit Information
$rimary diagnosis' 2econdary diagnosis' ((((((((((((((((((((((

$lease provide detailed information regarding the diagnosis that will help us work with
the participant effectively' ((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((
"edical Information
%ood allergies' 9es or &o /6f yes< please e"plain' 0
$lease e"plain any medical conditions or health concerns and any special instructions'
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
((((((((((((((((((((((((


#hoose A $ession
$lease number each session in order of preference. >nly mark the sessions you are able to
attend.
((((( 2ession 4 8'5 am - ?'@# am
%%%%% 2ession 2 4'# am - 44'2 am
((((( 2ession 5 44'@ am - 42'## pm
((((( 2ession @ 2' pm - 5'4# pm
((((( 2ession # 5'5# pm - @'# pm

Pament Information
$ayment of the camp fee is re=uired to process the registration form
$ayment by check enclosed payable to'
iCan Shine, Inc.
Registraions can be sent to Sean & Lori Frain, 131 Penfold Cr, Wpg, M,
R!"1S3
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Rider Information
This inor!ation helps "a!p sta # $olunteer spotters assigne% to &or' %ire"tly &ith the (i%er
un%erstan% an% )etter ser$e the in%i$i%ual nee%s o the (i%er*
AiderBs &ame' (((((((((((((((((((((((((((((&ickname' (((((((((((((((((
Age'((((((
+iagnosis /optional0' (((((((((((((((((((((((((((((
Please highlight the appropriate )o+ as it relates to the ri%er
9es 2ometimes &o
1an communicate his-her needs ((( ((( (((
When upset can manage his-her emotions ((( ((( (((
1onsistently follows simple directions ((( ((( (((
1ooperates with others ((( ((( (((
1omfortable with physical =ueues ((( ((( (((
)ikes to be playfully teased ((( ((( (((
,enefits by using pictures to convey meaning ((( ((( (((
*ets frustrated easily ((( ((( (((
Has trouble staying focused ((( ((( (((
*ets upset by loud< sudden noises ((( ((( (((
*ets upset by background noise such as music or talking ((( ((( (((
Please ans&er ea"h o the ollo&ing ,uestions -please use )a"' o or! i nee%e%./
4. What strategies do you use to promote positive behavior and-or discourage negative
behavior that will enable us to work safely and successfully with the riderC
2. What are favorite activities< movies< music< hobbies or other interests of the riderC
5. Has rider attended an i1an ,ike program /formerly )ose 7he 7raining Wheels0
previouslyC 9es &o 6f yes< when and what was the outcomeC

@. Has he-she ridden with training wheelsC 9es &o 6f yes< please provide a brief
history.
#. Has rider e"perienced a bicycling accidentC 9es &o 6f yes< please e"plainC
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+ocument 3 445A
Rider &iabilit Release

Aider &ame' ((((((((((((((((((((((((((((((((((((((((((((((((
PAR' I ("andator for Participation)
,y signing< 6 hereby e"pressly acknowledge that bicycling< like many sports such as
swimming< golf< soccer< and gymnastics involves movement and physical activity< and
that inDury or mishap are possibilities in spite of all reasonable safeguards and
precautions taken. %urther< 6 hereby e"pressly acknowledge that photographs and-or
videos of the above rider may be taken by parties outside the control of 2hine in
connection with participating in bike camp. 6 acknowledge that 2hine has limited or no
control over such activities of third parties and has no control over any editing and-or
use of such photos and-or video footage. As the parent-guardian of the above rider< 6
accept such risks as reasonable and proper< and agree to hold harmless the officers<
principals< staff and volunteers of 2ean and )ori %rain< i1an 2hine< 6nc.< and Aainbow
7rainers< 6nc. should inDury or mishap occur in this regard.
6 understand that data collected from this program will be used to help the camp operate
effectively relative to appropriate progressions< bike si8ing and behavior management. 6
acknowledge that 6 may be contacted in the future for follow up information pertaining to
rider progress< status or for other re=uests to support the future development and
success of the program.
2ignature of $arent-*uardian' (((((((((((((((((((((((((((((((((((((((
PAR' II ((ot "andator for Participation)
6 give permission for the above rider to be photographed and-or videotaped in print or
electronic media by 2hine or third parties acting on behalf of 2hine. 6 acknowledge and
agree that photographs and videos may be edited and used in whole or in part as
desired for the purpose< which may be produced< duplicated< distributed and used for
informational< promotional or other public purposes. 6 understand that photographs and
video are not my property and there will be no compensation to me. 6 understand and
authori8e the use in writing or otherwise the name or identity of the above rider.
2ignature of $arent-*uardian' (((((((((((((((((((((((((((((((((((((((
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