Bike Rodeo Permission Slip
Purpose
The bike rodeo is designed to get children active, increase safety, and reduce carbon emissions.
Children who participate in the bike rodeos receive instruction to improve road handling skills.
Program Objectives
The bike rodeo is part of San Mateo County’s Safe Routes to School (SR2S) initiative. The goals of
SR2S are to:
 Increase daily physical activity
 Increase pedestrian and bicyclist safety
 Reduce traffic in and around schools
 Improve air quality
Potential Risks
The bike rodeo is designed to reduce the risk of injury as children travel to and from school through
quality education. However, there are inherent risks associated with children riding bicycles and
those risks may be present during the bike rodeo.
Voluntary Consent
I certify that I have read this consent form or it has been read to me and that I understand the
potential risks. By signing this form, I agree to allow my child to participate in the bike rodeo. I
acknowledge that while adult(s) will supervise the children, they will not take personal
responsibility for the safety and welfare of individual children.
I have explained to my child the need for good behavior and accept that should my child disobey the
bike rodeo rules, he/she may be asked to leave rodeo activities.
I understand and agree that my son/daughter may be taken for medical assistance in the event of
serious injury and I agree that I will be solely responsible for any and all costs incurred as a result. I
further agree to hold harmless the Silicon Valley Bike Coalition, the City of Belmont, the BelmontRedwood Shores School District, 4-H, and the San Mateo County Office of Education, their sponsors,
employees and any volunteer for this event for injury that occurs to my child which is not the result
of action or inaction by the San Mateo County Office of Education, the district, the city, the school, or
their representatives.
Child’s Name
Age
Parent’s Name (Printed)
City of Residence
Email
Signature of Parent or Legal Guardian
School
@