Registration Ottawa-Gatineau-Montreal-Halifax
Please note that all fields followed by an asterisk must be filled in.
DISCLAIMER/REQUIREMENTS, All *
I have Chosen
Other/AUTRES
Date & length of last session / Date et durée de la dernière session
COMMENTS/COMMENTAIRES
Training Location / Lieu de formation*
---Select--- OTTAWA - Downtown
OTTAWA - Ontario
KANATA- Ontario
GLOUCESTER- Ottawa
NEPEAN - Ontario - 15 km South of Ottawa
NEPEAN - Ontario 15 km South of Ottawa, if there no availability here, I will come to Gatineau Quebec, 15 km North of Ottawa
GATINEAU - Quebec 15 km North of Ottawa
GATINEAU - Quebec 15 km North of Ottawa, if there no availability here , I will come to Nepean Ontario, 15 km South of Ottawa
KIRKLAND - Quebec
SENNEVILLE - Kirkland
SAINTE-ANNE-DE-BELLEVUE
MONTREAL QC - Downtown
DORION / Vaudreuil - Quebec
CORNWALLL - Ontario
Other Location, with this option I will provide a location that meets Born To Ride Bicycle's REQUIREMENTS
SAINT JOHN - New Brunswick
HALIFAX - Nova Scotia
DARTMOUTH - Nova Scotia
ADDITIONAL CITIES (Subject to approval) VILLES SUPPLÉMENTAIRES (Sous réserve d’approbation)
---Select--- PICKERING - STUDENT PROVIDES LOCATION
AJAX - STUDENT PROVIDES LOCATION
WHITBY - STUDENT PROVIDES LOCATION
OSHAWA - STUDENT PROVIDES LOCATION
BOWMANVILLE - STUDENT PROVIDES LOCATION
NEWVCASTLE - STUDENT PROVIDES LOCATION
BELLVILLE - STUDENT PROVIDES LOCATION
NAPANEE - STUDENT PROVIDES LOCATION
KINGSTON - STUDENT PROVIDES LOCATION
GANANOQUE - STUDENT PROVIDES LOCATION
DARLINGSIDE - STUDENT PROVIDES LOCATION
BROCKVILLE - STUDENT PROVIDES LOCATION
IROQUOIS - STUDENT PROVIDES LOCATION
OTHER ADDRESS / LOCATION PREFERRED
7. Type of Training*
Cycle Safety Training Techniques, Control, Interpretation, Communication Techniques de formation à la sécurité du cycle, contrôle, interprétation, communication
Tri-Trn'g pkg: 2 hr 1st time+ two 1-1/2hr sessions Tri-Trn’g pkg: 2 h 1ère fois + deux sessions de 1-1 / 2 heures
PENTATRACK-TRAIN’G PKG 1-30 MINUTYE PREP/EXERCISE + FIVE 1-1/2 HR PENTATRACK-TRAIN’G PKG 1-30 MINUTYE PREP/EXERCICE + CINQ 1-1/2 HR
MOMENTUM PKG 1-30 MIN+1-2HR 1ST TIME+FOUR 1-1/4 HOUR S'SSN MOMENTUM PKG 1-30 MIN+1-2HR 1ÈRE FOIS +QUATRE 1-1/4 HEURE SSN
CHILDREN PKG 1-2 HR + FIVE 1-1/4HOUR S'SSNS CHILDREN PKG 1-2 HR + FIVE 1-1/4HOUR S'SSNS
CHALLENGING CHILDRENS PKG 1-30MIN+1 1-1/2HOUR+6 1-1/4 HOUR S'SSN DÉFIER LES ENFANTS PKG 1-30MIN +1 1-1/2HOUR+6 1-1/4 HEURE SSN
ONE 3 HOUR TWO STUDENT PKG UNE 3 HEURES DEUX ÉTUDIANTS PKG
TWO 3 HOUR TWO STUDENT PKG DEUX 3 HEURES DEUX ÉTUDIANTS PKG
THREE 3 HOUR TWO STUDENT PKG TROIS 3 HEURES DEUX ÉTUDIANTS PKG
ASSESSMENT 45 MINUTES limited available dates/times ÉVALUATION 45 MINUTES dates/heures limitées disponibles
2 hour Learn To Ride Session, Available after 1st Training Package is completed, Subject to approval Session d’apprentissage de 2 heures, disponible après la 1ère trousse de formation, sous réserve d’approbation
1-1/2 hour Learn To Ride Session, Available after any 2 hour session, Subject to approval 1-1/2 heure Apprendre à rouler Session, Disponible après toute session de 2 heures, Sous réserve d’approbation
L-Ride Pkg two - 3 hrs + 1-1/2hr session L-Ride Pkg deux - 3 heures + 1-1 / 2 heures de session
YOUTH with one Adult 19yrs+ L-Ride Pkg: 1-1/2 hr session JEUNESSE avec un adulte 19 ans + L-Ride Pkg: 1-1 / 2 session d’heure
OTHER / AUTRES
I realize both / Je me rends compte des deux*
PLEASE*
CUSTOMER IS THE / LE CLIENT EST LE*
---Select--- STUDENT
SPOUSE
PARENT
GUARDIAN
GRANDPARENT
AUNT
UNCLE
NEPHEW
NIECE
FREIND
SPONSOR
DISTANCE RELATIVE
OTHER: DETAILS BELOW
OTHER
CUSTOMER, Rank your Pain Factor (Do Not complete if you are the STUDENT) CLIENT, Classez votre facteur de douleur (Ne pas compléter si vous êtes l’ÉTUDIANT)
---Select--- 1. I am constantly taking pain killers
2. I fall apart at the first onset of any discomfort or pain
3. If I'm not comfortable, I feel, I can't do it
4. If I get a scratch, I feel I need immediate attention
5. I don't see the benefit of discomfort or pain
6. I can withstand a scratch, bruise or fall here or there
7. Anything worthwhile involves experiencing some form of discomfort or pain
8. Discomfort or pain doesn't bother me
9. No Pain, No Gain
10. I am athletic, and work out on a regular basis. PAIN = GAIN
11. Life's full of risks, and I'm willing to take it all on!
CUSTOMER / CLIENT*
CUSTOMER, IF YOU DO, HOW DID YOU LEARN TO RIDE ? / CLIENT, SI VOUS LE FAITES, COMMENT AVEZ-VOUS APPRIS À ROULER ?
CUSTOMER, First and Last Name*
Last Name*
Cell Phone 1-*
Alternative Phone 1-
E-Mail Address*
Street Address*
C I T Y and Postal / Zip Code*
Best days & hours to Call / Meilleurs jours et heures d’appel*
1. Cell Phone# on the day of the training / 1. Numéro de téléphone cellulaire le jour de la formation
I agree to provide / J’accepte de fournir *
Provide STUDENT a)___F U L L_____N A M E (S) / Fournir à STUDENT a)___F U L L_____N A M E (S)*
Student a) Rank your Pain Factor Étudiant a) Classez votre facteur de douleur*
---Select--- 1. I am constantly taking pain killers
2. I fall apart at the first onset of any discomfort or pain
3. If I'm not comfortable, I feel, I can't do it
4. If I get a scratch, I feel I need immediate attention
5. I don't see the benefit of discomfort or pain
6. I can withstand a scratch, bruise or fall here or there
7. Anything worthwhile involves experiencing some form of discomfort or pain
8. Discomfort or pain doesn't bother me
9. No Pain, No Gain
10. I am athletic, and work out on a regular basis. PAIN = GAIN
11. Life's full of risks, and I'm willing to take it all on!
Provide STUDENT b) ___F U L L_____N A M E (S) / Fournir STUDENT b) ___F U L L_____N A M E (S)
Student b) Rank your Pain Factor / Étudiant b) Classez votre facteur de douleur
---Select--- 1. I am constantly taking pain killers
2. I fall apart at the first onset of any discomfort or pain
3. If I'm not comfortable, I feel, I can't do it
4. If I get a scratch, I feel I need immediate attention
5. I don't see the benefit of discomfort or pain
6. I can withstand a scratch, bruise or fall here or there
7. Anything worthwhile involves experiencing some form of discomfort or pain
8. Discomfort or pain doesn't bother me
9. No Pain, No Gain
10. I am athletic, and work out on a regular basis. PAIN = GAIN
11. Life's full of risks, and I'm willing to take it all on!
Student a) Gender / Élève a) Sexe*
Student b) Gender / Élève b) Sexe
OTHER/AUTRES
Student a) Age / Étudiant a) Âge*
Student b) Age / Étudiant b) Âge
Student a) Height (inches") / Élève a) Hauteur (pouces)*
Student b) Height (inches") / Élève b) Hauteur (pouces)
Student a) Weight (lbs)*
Student b) Weight (lbs) / Élève a) Poids (lb)
part 2 Student a) Divide weight/height / partie 2 Élève a) Diviser poids/taille*
part 2 Student b) Divide weight/height / partie 2 Élève b) Diviser poids/taille
Student a) **CRITICAL** (measure floor to highest point between legs) Inches" TO ENSURE TOP TUBE CLEARANCE ON TRAINING BICYCLE INSEAM (INCHES") / Élève a) **CRITIQUE** (mesurer le sol jusqu’au point le plus élevé entre les jambes) Pouces » POUR ASSURER LE DÉGAGEMENT DU TUBE SUPÉRIEUR SUR L’ENTRAÎNEMENT DU VÉLO INSEAM (POUCES »)*
Student b) **CRITICAL** (measure floor to highest point between legs) Inches" TO ENSURE TOP TUBE CLEARANCE ON TRAINING BICYCLE INSEAM (INCHES") / Élève b) **CRITIQUE** (mesurer le sol jusqu’au point le plus élevé entre les jambes) Pouces » POUR ASSURER LE DÉGAGEMENT DU TUBE SUPÉRIEUR SUR L’ENTRAÎNEMENT DU VÉLO INSEAM (POUCES »)
I*
FOR MULTIPLE STUDENTS Please complete add'l information here, B) Name/Gender M,F/Age-yrs/Inseam"/Height' "/Weight-LBS/Pain Factor/ helmet size(s) OR EMAIL DIRECTLY TO info@borntoridebicycle.com wityh subject Learn To Ride w/Your full name / POUR PLUSIEURS ÉTUDIANTS S’il vous plaît compléter add’l informations ici, B) Nom / Sexe M, F / Age-yrs / Inseam"/Taille' « /Poids-LBS / Facteur de douleur / taille du casque (s) OU E-MAIL DIRECTEMENT À info@borntoridebicycle.com wityh sujet Apprendre à rouler w / Votre nom complet
comments/commentaires
I will need / J’en aurai besoin
comments/commentaires
I accept / J’accepte*
Student a) Helmet options*
STUDENT a) Helmet size (Teens - Adult)
Student b) Helmet options
STUDENT b) Helmet size (Teens - Adult)
Additional Students information
Why do you feel, you need training?
What motivates you (student) to learn to ride a bicycle?
Choose what best describe Your scenario*
Other
I wish to experience
OTHER
HEALTH & WELLNESS
Does the student(s) have a learning disability, mental or physical challenges*
Does the Student(s) have any health issues, if yes, you may be required to complete an assessment.**
If "Yes" please specify , . Provide links to website, for support on this topic
In preparation for my training session(s), I will complete the following activities sports and/or exercises *
Other Cardio/intensity
How often will you complete the above sports/exercises prior to your session*
A. I WISH TO START MY TRAINING IN THE MONTH(S) OF
B. Preferred Day(s)*
C. Preferred Time(s) two 2*
D. Preferred Dates, Special Requests
1-A I agree to the following*
2-B I acknowledge*
3-C I agree to the following*
4-D I realize*
5-E I accept that*
6-F I acknowledge:*
7-G I accept that*
comments