Story Riders x Pueblo Resurgents in Isleta Pueblo

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For questions, please contact Program Manager Marco Sandoval at marco@centerofsouthwestculture.org or call (505) 200-9907.We will begin and end the program at the Isleta Youth Recreation Center every day. Please refer to our Parent/Student Handbook for more information.

Student Information

Student's First Name *

Student's Last Name *

Grade *

School student attends *

Student Age *

Student height *

Does your student have a bike they can use for the program? (We will provide one if they don't have one.) *

Yes

No

Does your student know how to ride a bike? If not, we can teach them! *

Yes

No

I understand that if the participant misses 3 or more classes they are NOT eligible to receive a bike and a helmet. *

I understand

I understand that if the family needs to store a bike after the program, we can only hold it for two weeks and after that time, it will be recycled back into the program. *

I understand

Student Primary Address *

City *

Zip Code *

Race/Ethnicity *

Please click on the link below to ensure registration *

Afterschool, 4:30pm to 6:30pm (11 remaining)

Contact Information

Parent or Guardian 1

First Name *

Last Name *

Phone Number *

Work Phone #

Email Address *

Parent or Guardian 2

First Name

Last Name

Do you hereby give permission for photos and videos to be taken of the child listed above by the Center of Southwest Culture/Story Riders to be used for documentation, promotion and outreach purposes, newsletters, commercials, promotional videos, CSC's website, other social media platorms, flyers, brochures, and educational projects? *

Agreement for Liability Waiver

Participation in Story Riders events may involve known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to participants, to property, or to third parties. The risks include, among other things: falling off the bicycle due to rider error, bicycle malfunctions, altercations with other students, collisions with other riders, pedestrians, equestrians, obstacles such as loose sand and/or rocks on the trail, collisions with trees, low-hanging branches, bushes, logs, rocks and vehicles. Other risks of activity in the outdoors include insect and animal bites as well as weather-related injuries (due to heat, wind, excessive sun). Any of these risks could lead to foreign objects in eyes, heat-stroke, dehydration, broken bones, concussions, cuts and scrapes, bruises, internal organ damage, fainting, emotional stress, and/or death. Because of the dangers of participating in this activity, the undersigned parent and/or legal guardian and participant agree to fully comply with any supervisor’s instructions regarding participation in this activity.

Acknowledgment and Assumption of Risk

The undersigned parent and/or legal guardian does hereby acknowledge that he/she is aware of the dangers and the risks to the participant’s person and property involved in participating in Center of Southwest Culture (CSC) activities and agrees to accept and assume all the risks existing in this activity. Participation in these activities is purely voluntary and the undersigned elect to participate in spite of the risks. The undersigned parent and/or legal guardian and participant understand that the Center of Southwest Culture does not insure participants in the above-described activity, that any coverage would be through personal insurance, and that CSC has no responsibility or liability for injury resulting from this activity.

Consent is given for the participant to receive medical treatment, which may be deemed necessary or advisable in the event of injury, accident or illness during this activity or event. This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

*

I, the undersigned parent or legal guardian affirm that I am freely signing this agreement.

I hereby accept and assume any and all risks of property damage, personal injury, or death.

I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to myself and/or the minor participant regarding any losses the participant may sustain as a result of participation in the activity. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

Medical Information and Agreement for Medical Attention

The Center of Southwest Culture (CSC) wishes to avoid difficulties in obtaining medical services for children who may become ill or injured during CSC program activities. As the parent/guardian of a child participating in a CSC activity, it is necessary that you consent, in advance, to hospitalization, medical attention, or surgery for your child in case an emergency occurs. If no consent is given, you must provide a written statement of procedures to be followed if your child is injured or becomes ill during a program activity. In the event of serious illness or injury a reasonable effort will be made to contact you to obtain further verbal consent in advance of medical services being given. If we are unable to contact you, CSC staff will consent to such services for your child by acting on your behalf based on written advance authorization. That authorization is the consent below. *

I have read the above and hereby designate the Center of Southwest Culture staff to act on my behalf in the event of a medical emergency involving my child. CSC staff members may authorize such hospitalization, medical attention, or surgery as may be required in an emergency because of illness or injuries sustained by my child while participating in CSC sponsored activities. I hereby assume all financial responsibility for hospitalization, medical attention, and surgery provided.

This program involves a lot of physical activity. Please provide the following information to help ensure the safest, most successful experience for your child:

Medical concerns/physical conditions (including allergies, diseases, disabilities, etc.) of your child: *

Prescription and over-the-counter medication being taken by the student: *

Dismissal

Please select ALL that apply *

My child is to be picked up from Story Riders from an authorized person.

I hereby DO give permission for my child to leave the program upon dismissal. I understand that the Center of Southwest Culture/Story Riders is not responsible for my child once they have been dismissed from the program.

Confirmation

*

I hereby confirm that this document was filled out by an authorized Parent or Guardian of the above-mentioned student participant.