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2. 
4. Release, Waiver and Indemnification Agreement
6. Program/Activity

   Pedal 1804 Bike Ride

7. Date

   Sunday, May 18, 2025

9. Participant's Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Birth date*
    Birth date
18. Phone Number*
20. Email Address*
22. Parent or Guardian Name*

    (If the participant is under the age of 18)

23. Phone Number*
25. Emergency Contact*
26. Phone Number*
28. Physician's Name
29. Phone Number
33. I, the undersigned participant, whose name appears above, voluntarily consent and agree to participate in this non-commercial, community-oriented, or school-supported program/activity.

    By executing this document, the undersigned further agrees to the following:

    • WAIVE ANY CLAIM against the City of North Miami (“City”) and its officers, agents, and employees arising from any loss, injury, or damage to person or property and does COVENANT NOT TO SUE the City and its officers, agents, and employees.
    • RELEASE, INDEMNIFY, AND HOLD HARMLESS the City and its officers, agents, and employees from all claims, suits, actions, demands, rights, court judgments, or expenses arising from or because of all known or unknown damages, claims or actions arising from participation in the above-described program/activity. 
    • Nothing contained in this Agreement is in any way intended to be a waiver of the limitation placed upon the City’s liability as outlined in Section 768.28, Florida Statutes. Additionally, the City does not waive sovereign immunity, and no claim or award against the City shall include attorney’s fees, investigative costs, or pre-judgment interest. 
    • Authorize the City of North Miami and its officers, agents, employees, and sponsors to call my physician and to arrange for transportation to a hospital in the event of any injury to the participant, although I understand that the City of North Miami and their officers, agents, employees, and sponsors assume no responsibility to do so. 
    • Authorize the City to depict for any purpose, without paying compensation to me, my name, image, or my likeness in photographic or other works appearing in all media (presently known or unknown) worldwide. 
    • In the event the participant is under the age of 18, both parents or guardians of the participant, consent and agree that the program/activity named above provides the participant's child with an essential element of knowledge or life skill that may personally benefit the participant’s development in society. 
    • In the event any portion of this Agreement is deemed to be void, the undersigned specifically agree to waive all claims, including but not limited to claims for medical expenses, future cost of medical bills, pain and suffering, and emotional distress, against the city and its officers, agents, and employees. 
    • The City desires to enter into this Agreement only if in so doing the City can place a limit on its liability for any cause of action for money damages or arising out of this Agreement, so that its liability never exceeds the sum of $1,000.00. Participant, or both parents or guardians (if the participant is under the age of 18) individually, hereby expresses its willingness to enter into this Agreement with recovery from the City for any action or claim arising from this Agreement to be limited to the sum of $1,000.00. 
    • This Agreement shall be binding on all heirs, successors, and assigns of the participant, or if the participant is under the age of 18, of each parent or guardian.
35. All the undersigned have fully read, understood, and agreed to each term in this Release, Waiver, and Indemnification agreement.

37. All of the undersigned have fully read, understood and agree to each and every term contained in this Release, Waiver and Indemnification agreement.

39. Signature of Participant*

    (Parent or Guardian Signature if participant is under the age of 18)

41. Name*
43. Address*
45. City*
46. State*
47. Zip Code*
49. Phone Number*
50. Email Address*
52. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
54. Electronic Signature*

    (Parent or Guardian Signature if participant is under the age of 18)

56. Today's Date*
    Today's Date
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field