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The Fix Permission & Release Form

Please read through each section and sign at the end of the form in recognition of your acceptance.

Program Permission

I give my permission for my child to participate in The Fix bike repair program.

I Agree

Bike Riding Permission

Open Roads often offers to take its students on at least one short bicycle ride. Open Roads’ rides operate under the supervision of a trained Open Roads’ employee or volunteer, occur during program hours, and at times may include riding on city streets with traffic.

I give my permission for my child to participate in bicycle rides while under the supervision of Open Roads’ staff and volunteers.

I Agree

Permission to Use Name and Likeness

Open Roads frequently photographs and films its students participating in the various activities and programs to use for promotional and marketing materials for Open Roads programs. Before Open Roads can do so, your permission is needed to display these images or to use the name of your child.

I grant Open Roads permission to use images of my child.

I Agree

I grant Open Roads permission to use my child’s name.

I Agree

I grant Open Roads permission to use verbal or written statements from my child.

I Agree

Permission to Seek Medical Attention

If your child is injured while participating in an Open Roads program or event, Open Roads will make every effort to contact you or the emergency contacts listed below, however if we are unable to, Open Roads needs your authorization to allow trained staff to perform CPR or first aid for minor injuries.

I grant Open Roads permission to perform CPR and first aid on my child.

I Agree

In the event of a major injury or medical emergency requiring professional help from a medical facility or an emergency medical service, Open Roads needs authorization to seek medical attention for the student and to transport the student if necessary.

Open Roads will not be held responsible for any costs associated with the seeking of professional medical help.

I grant Open Roads permission to seek professional medical help.

I Agree

I grant Open Roads permission to transport my child to a medical facility during a medical emergency.

I Agree

Release of Liability

In consideration of my child being allowed to participate in the Open Roads The Fix program (Program), I release from liability and waive my right to sue Open Roads, their employees, directors, officers, volunteers and agents (collectively “Open Roads”) from any and all claims, including claims of the Open Roads’ negligence, resulting in any physical injury, illness (including death) or economic loss I or my child may suffer or which may result from my child’s participation in the Program or any events incidental to the Program.

I acknowledge the inherent risks and hazards in bicycle related activities, including those that take place during and as a result of the Program. I realize that those risks include, but are not limited to, injuries, accidents, equipment and tool failure, incorrect instruction, and inattentive supervision. I understand that these risks, as well as others, are unforeseeable, unpredictable accidents and I assume all risks associated with such accidents, even though I cannot foresee them.

This Release applies to and binds my personal representatives, heirs, and my family.

I have read the paragraph above and understand I am releasing Open Roads and its associates from all legal liability.

I Agree

Sign below in recognition of the permissions and releases you are granting above:

* All references to “Open Roads” shall be construed as a reference to the “Open Roads Bike Program”

Date: September 13, 2025

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Age
Name of School:
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Age
Name of School:
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Age
Name of School:
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Age
Name of School:
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Age
Name of School:
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Age
Name of School:
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Age
Name of School:
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Age
Name of School:
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Age
Name of School:
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Age
Name of School:
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Age
Name of School:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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