Rider Registration Form
HRCA Therapeutic Recreation
June 15-19, 2015
Eastridge Recreation Center
9568 University Blvd, Highlands Ranch, CO 80126,
Cost: member $260/ program guest $300
We are pleased to offer this bike program to people with disabilities and look forward to
helping your family member learn to ride a two-wheel bicycle independently.
Requirements for Participation (Rider must meet all of below criteria):
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Minimum of 8 years of age
Have a disability
Able to walk without assistive device
Willing and able to wear a properly
fitted bike helmet
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Able to sidestep to both sides
Able to attend camp all 5 days
Maximum weight 220 lbs.
Minimum inseam of 20” (measure from
floor while rider is wearing sneakers)
***All fields are required. Registration will not be accepted if this form is incomplete.***
Sessions fill quickly. Don’t delay in submitting your forms.
Rider/Family Information:
Rider Name:
Rider Nickname, if any:
Rider Gender (M or F):
Rider Date of Birth:
Age (Time of camp):
Rider Height:
Rider Weight:
Rider Inseam (inches from
floor while wearing sneakers):
Rider T-Shirt Size:
Additional shirts ($10 ea.):
Youth L
Adult S
Adult M
Adult L
Adult XL
(Please indicate no. & sizes)
Parent/Guardian Name:
Parent/Guardian E-Mail:
Parent/Guardian Phone:
Parent/Guardian Cell Phone:
Home Address:
Emergency Contact Name:
Emergency Contact Phone:
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Disability Information:
Primary Diagnosis:
Secondary Diagnosis, if any:
Please provide detailed information regarding the above diagnoses that will
help us work with the rider effectively (boxes will expand if more room is
needed):
Health Information:
Rider Food Allergies, if any:
Please explain any health/medical conditions or health concerns and any
special instructions:
Choose A Session:
Please number each session in order of preference (i.e. 1st, 2nd 3rd).
Session #1: 8:15 am – 9:30 am
Session #2: 9:50 am – 11:05 am
Session #3: 11:25 am – 12:40 pm
Session #4: 1:45 pm – 3:00 pm
Session #5: 3:20 pm – 4:35 pm
Please plan to arrive 15 minutes prior to your session start time.
A parent or guardian must be present for the duration of all your child’s sessions.
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Rider Information:
This information helps camp staff & volunteer spotters assigned to work directly
with the Rider understand and better serve the individual needs of the Rider.
Please place an ‘X’ in the box that most appropriately describes the Rider:
Generally speaking, the Rider….
can communicate his/her needs
when upset, can manage his/her emotions
follows simple directions
cooperates with others
is comfortable with physical queues/prompts
responds positively to playful banter
benefits from use of pictures to convey meaning
gets frustrated easily
has trouble staying focused
gets upset by visual or audio stimuli (eg. bright lights, loud noise)
gets upset by background noise such as music or talking
Comments/Additional Information:
Yes
Sometimes
No
Please answer each of the following questions:
1. 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 rider?
2. What are favorite activities, movies, music, hobbies or other interests of the rider?
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3. Has rider attended an iCan Bike program (formerly Lose The Training Wheels)
previously? If yes, when and what was the outcome?
4. Has he/she ridden with training wheels? If yes, please provide a brief history.
5. Has rider experienced a bicycling accident? If yes, please explain.
6. Through participating in this iCan Bike program, what are your expectations for your
rider?
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Please plan to attend the mandatory parent meeting at Eastridge Recreation
Center on Sunday, June 14th from 3:00-4:30pm. (Check-in opens at 2:45 pm).
There will be an end of camp celebration party on Friday, June 19th at 5 pm.
Would you be interested in volunteering to be a spotter for another child?
Yes
No
if Yes, which session(s)
1
2
3
4
5
Parents will not be allowed on the bike floor unless they sign up to be a spotter for another child
Cancellation Policy
If a family wishes to cancel their registration a refund will be given if the campers
slot can be filled less the administrative fee of $5.
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Consider making or saving a copy of your registration form before submitting
as it contains important details for your reference.
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If a camper already has a bike, they should plan to bring it on Monday, June
15th for evaluation by the Bike Tech. If they do not have a bike, we will
provide useful information at the June 14th mandatory meeting for finding a
suitable bike. If you need to purchase a bike for your camper, the Highlands
Ranch BikeSource is the Colorado bike shop sponsor. We have trained their
staff and they have bikes stocked for the campers at a discount. These
discount coupons will be provided.
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We can’t emphasize enough that the success of your camper in learning to
ride a bike is highly dependent on family follow through after camp. What
each camper learns at camp will need to be reinforced consistently
throughout the summer.
Submission Instructions:
Please mail this completed registration form with payment to Summer Aden,
Southridge Recreation Center, 4800 McArthur Ranch Rd, Highlands Ranch, CO
80130 or e-mail to [email protected]
Payment Information:
Payment of the camp fee is required to process the registration form. Please
include check payable to HRCA OR complete below Credit card information:
Member $260/ program guest $300
Name on Credit Card:
Credit Card #:
Expiration Date:
Security Code:
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Rider Liability Release
Rider Name:
By signing, I hereby expressly acknowledge that bicycling, like many sports such
as swimming, golf, soccer, and gymnastics involves movement and physical
activity, and that injury or mishap are possibilities in spite of all reasonable
safeguards and precautions taken. Further, I hereby expressly acknowledge
that photographs and/or videos of the above rider may be taken by parties
outside the control of Shine in connection with participating in bike camp. I
acknowledge that Shine 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, I accept such risks as
reasonable and proper, and agree to hold harmless the officers, principals, staff
and volunteers of Highlands Ranch Community Association, Therapeutic
Recreation Program, iCan Shine, Inc., and Rainbow Trainers, Inc. should injury or
mishap occur in this regard.
I understand that data collected from this program will be used to help the
camp operate effectively relative to appropriate progressions, bike sizing and
behavior management. I acknowledge that I may be contacted in the future
for follow up information pertaining to rider progress, status or for other requests
to support the future development and success of the program.
Parent/Guardian Signature:
I give permission for the above rider to be photographed and/or videotaped in
print or electronic media by Shine or Highlands Ranch Community Association,
Therapeutic Recreation Program or third parties acting on behalf of Shine or
Highlands Ranch Community Association, Therapeutic Recreation Program. I
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. I understand that photographs and video are not my property and
there will be no compensation to me. I understand and authorize the use in
writing or otherwise the name or identity of the above rider.
Parent/Guardian Signature:
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Personal Care
It is the HRCA Therapeutic Recreation program policy that all personal care, including transfer if
required, are the responsibility of the participant, guardian, or caregiver.
Cancellation/ Billing Policy
Our staffing for 1:1 instruction is arranged by appointment. An appointment cancellation with
less than 24 hours notice will result in a charge equal to the hourly fee.
NOTICE: By enrolling or participating in any program and recreational activity provided or
sponsored by the Highlands Ranch Community Association, Inc. (HRCA), members and
guests acknowledge and agree that there are certain risks inherent in the programs and
activities conducted at the HRCA’s Recreational Facilities or off-site programs, which the
members and guests assume. By enrolling or participating in any program and recreational
activity, members and guests agree to waive any claim of liability against the HRCA and its
members, directors, officers, agents, employees and contractors, related entities and
affiliates and their agents and employees, arising out of any loss, injury, or death attributed
to such risks and the use of the HRCA’s Recreation Facilities or off-site programs.
Responsibility for Emergency Care: In consideration of the possibility of an accident,
PARTICIPANT or PARTICIPANT’S parents or legal guardian hereby consents to emergency
transportation and treatment necessary in the event of injury or illness. PARTICIPANT or
PARTICIPANT’S parents or legal guardian hereby accepts responsibility for the payment of any
emergency transportation and treatment expenses and any subsequent medical bills.
PARTICIPANT or PARTICIPANT’S parent or legal guardian acknowledges that the HRCA has not
purchased any health or accident insurance to cover such expenses.
Physician’s Examination: PARTICIPANT or PARTICIPANT’S parents or legal guardian understands
and agrees that, although a physician’s examination is not required to participate in the
programs and activities offered by the HRCA in the Therapeutic Recreation program, that it is
highly advisable that participant consult with and be examined by a physician before
participating in any athletic and/or strenuous activities.
Appropriate Social Behavior: Participants will demonstrate appropriate social behavior.
Continuous unsafe behaviors (hitting, kicking, self-abusing, verbal outbursts, or refusal to stay or
participate, with group/activity) cannot be tolerated in the community recreation setting. When
this type of behavior is demonstrated in the recreation setting, the Therapeutic Recreation staff
member will provide intervention that is appropriate for the developmental age and ability of
the participant. If the participant is unable to respond to the intervention, the participant’s
parent/guardian will be notified and the parent/guardian will be asked to pick up the
participant from the program.
If the participant is to continue in the Therapeutic Recreation program, the parent/guardian
must consult with the Therapeutic Recreation staff and, when indicated, a behavioral plan will
be designed by the Therapeutic Recreation Specialist, in conjunction with the parent or
guardian.
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Participant and/or parents or legal guardian, if applicable
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Date
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