Bike Rodeo Registration

Bike Rodeo Registration Form

I consent that the below mentioned participants are given permission to participate in PennDOT's Bike Rodeo. I do this with full knowledge that they must be wearing a proper bike helmet and that riding a bike and participating in the prepared events has an inherit risk of crashes and accidents. I will not hold PennDOT or any of the affiliated partners responsible for any injuries that may occur.

Participant Information

Participant Name

Participant Age

Participant Hometown

Participant Name

Participant Age

Participant Hometown

Participant Name

Participant Age

Participant Hometown

Participant Name

Participant Age

Participant Hometown

Participant Name

Participant Age

Participant Hometown

Parent/Guardian Information

First Name

Last Name

Email Address

Photo Release

Agreement

Signature

Electronic Submission. Under penalties of perjury I certify that I am the person accessing this web page and submitting the Department of Transportation. By selecting I Agree and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature. I understand that I can be prosecuted if I provide false or misleading information. RELEASE OF INFORMATION: I verify that the information provided in this document is true and accurate. I understand that I may be subject to the criminal penalties prescribed by 18 Pa. C.S.A. Section 4904 for unsworn falsifications to authorities if there are false statements in this document.

I hereby consent to the Commonwealth of Pennsylvania, Department of Transportation (“PennDOT”), using my likeness, including but not limited to, my name, photograph, image, voice, or a substantially similar imitation of one or more thereof. I hereby consent to PennDOT recording or reproducing my likeness in any PennDOT-related publication or media activity.

I consent to PennDOT being the exclusive owner of any intellectual property rights as they relate to any original material it creates by using my likeness.

I agree to indemnify and release PennDOT and its agents, licensees, and contractors (including photographers or videographers) from any claims that may arise as they relate to the use of my likeness.

I agree this release shall be effective as of the date of signature below and remain in effect in perpetuity.

I have read and fully understand this release and intend to be legally bound by its terms.