Bike Riding Clinic Registration
📍 Location: City Park Festival Grounds – Reunion Shelter
Select Session
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Session 2: November 2, 3 & 9, 10 (Monday & Tuesday)
Session 3: November 16, 17 & 23, 24 (Monday & Tuesday; Thanksgiving Week)
Session 4: November 30, December 1, & 7, 8 (Monday & Tuesday)
Select Time (Session 1: October 19, 20, & 26, 27 every Monday & Tuesday)
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4:00 - 4:30 PM
4:30 - 5:00 PM
Select Time Session 2: November 2, 3 & 9, 10 every Monday & Tuesday)
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4:00 - 4:30 PM
Select Time (Session 3: November 16, 17 & 23, 24 every Mon & Tue; Thanksgiving Week)
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4:00 - 4:30 PM
4:30 - 5:00 PM
Select Time (Session 4: November 30, December 1, & 7, 8 every Monday & Tuesday)
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4:00 - 4:30 PM
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Child's Information
Participant Full Name
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First Name
Last Name
Birthdate
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Grade
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Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Child's School
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Parent / Guardian Information
Parent/Guardian's Name
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First Name
Last Name
Email
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example@example.com
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
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Zip Code
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List all persons who will be picking up your child (Name and Contact Number)
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Emergency Contact Name (Other than Parent/Guardian)
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First Name
Last Name
Emergency Contact Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Child's Background History
Has or does your child receive physical, speech-language therapy or occupational therapy?
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Yes
No
If your child received/receives physical, speech-language, or occupational therapy -- please provide location and frequency.
Are you currently receiving or have you previously received OT at Kim4Kids in the last 12 months?
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Yes
No
Does your child have ANY allergies?
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Yes
No
If your child has food allergies, please list all allergies and reactions.
Does your child take any medications?
Yes
No
If your child takes medications, please list below.
Please tell us anything else that would be helpful to us when working with your child.
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Does Kim4Kids have permission to take photo/video of your child to be used for marketing purposes͕ including social media posts.
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Yes
No
Liability Waiver
Kim4Kids Bike Clinic is a ride at your own risk program. We do our best to provide scaffolding support to minimize falls, but there is an assumed risk of falling, as your child learns and prepares to ride a bike independently. We require helmet and socks with closed toe shoes. You may provide additional elbow and knee pads if you like.
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Agree.
Total Registration Fee
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Bike Riding Clinic
$300.00
$
300.00
Debit or Credit Card
Credit Card Number
Security Code
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