2024 Bike Camp Registration | Tater Tots Pediatric Therapy

Participant Information *

First

Last

Age *

Race/Ethnicity (Optional)

Other

Gender Identification (Optional)

Female
Male
Other

Other

Pertinent Health Diagnoses *

Answer "none" if not applicable

Needed Adaptations for Participation *

Answer "none" if not applicable

Allergies *

Answer "none" if not applicable

Primary Contact *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Secondary Contact

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Other Persons Allowed to Pick Up or Drop Off

Does the Participant Own a Helmet *

Yes
No

If you answer yes, please bring the helmet with the child to bike camp.

What Size Helmet Does the Participant Need?

Small: 50-54 cm
Medium: 54-58 cm
Large: 58-61 cm

To measure your child’s head please use a cloth measuring tape. If you do not have a cloth measuring tape, you can use a piece of string, ribbon or shoelace to measure the circumference of your child’s head and lay it against a ruler to get the appropriate measurement. 1.) Start by measuring just above the ear. 2.) Wrap the measuring tape around the head, passing 1” above the eyebrows in front, above the other ear, and around the back of the head. 3.) Record the measurement at the mark where the two ends of the measuring tape or string meet. Use the sizing guidelines below to select the appropriate size helmet.

Rider's Height *

Rider's Weight (lbs) *

Inseam (Inches) *

Rider's T-Shirt Size *

Does the Participant Have Their Own Bike They Would Like to Bring to Camp? *

Yes
No

Describe the Participant's History and Experience with Biking *

What Do You Believe to Be the Primary Challenge for the Participant in Bicycling? *

Has the Participant had any Negative Experiences with Bicycling in the Past? *

What is the Participant's Primary Goal? *

(e.g. family outings, biking independently with peers, riding to school or work, etc.)?

What Have You, and/or Others, Tried so Far in Teaching the Particpant to Ride a Bike? *

Who in Your Family Rides a Bike and Will Be Riding with the Participant After Camp is Finished? *

Does the participant make eye contact? *

Yes
No
Sometimes
With Prompts

Does the participant like to be touched to help re-direct? *

Yes
No
Sometimes
With Prompts

Does the participant like to be touched to express comfort? *

Yes
No
Sometimes
With Prompts

Does the participant like to be playfully teased? *

Yes
No
Sometimes

Does the participant get frustrated easily? *

Yes
No
Sometimes

Does the participant have anxiety? *

Yes
No
Sometimes

Can the participant follow 1-3 step directions? *

Yes
No
Sometimes

Can the participant follow more than 3 step directions? *

Yes
No
Sometimes

Is staying focused a challenge for the participant? *

Yes
No
Sometimes

Would the participant benefit from using pictures to help convey meaning, actions or the day's schedule? *

Yes
No
Maybe

What specific things (object, words) interest or motivate the participant? *

Preferred Session *

9:00 AM - 10:15 AM
10:30 AM- 11:45 AM

Optional Donation

Participation in bike camp is free, but donations are welcome, with all proceeds going back into the program.

Other

Photo and Video Release *

I/We hereby give consent to Tater Tots Pediatric Therapy to photograph our child/self to educate others about the programs and services offered by Tater Tots Pediatric Therapy. Among the uses contemplated are illustration of articles in newsletters, in profiles that contributors receive, in brochures, to illustrate services discussed on the website, in displays at community fairs, to publicize local programs, to make professional presentations, to conduct research on teaching techniques and equipment used at the clinic, and to publicize the equipment and teaching methods used. In giving approval, I/we understand it is without consideration of compensation of any kind, and Tater Tots Pediatric Therapy is released from any claims or liability.

Signature *

You agree your E-Signature is the legal equivalent of your manual signature on this registration form, as if actually signed by you in writing.

Medical Release *

In the event that an emergency requiring medical or surgical care or treatment should arise while our child is attending the Tater Tots Pediatric Therapy Bike Camp, and I/We ARE NOT PRESENT TO MAKE MEDICAL DECISIONS, I/we give consent for the Tater Tots Pediatric Therapy camp staff to select and designate nurses, physicians, emergency medical staff (EMS) and surgeons to furnish such medical and/or surgical care as, in the judgment of a physician and/or surgeon holding a physician’s certificate issued by the Board of Medical Examiners of the State of Oregon may be needful and proper. I/We absolve Tater Tots Pediatric Therapy, and nurses, physicians, EMS personnel, and surgeons selected and designated by them, from any and all liability for their acts rendered in good faith.

Signature *

You agree your E-Signature is the legal equivalent of your manual signature on this registration form, as if actually signed by you in writing.