Child's First Name
Child's Last Name
Child's Date of Birth
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Is your child new to Variety?
What is your child's race/ethnicity?
- Select - American Indian or Alaskan Native Asian/Pacific Islander Black or African American Hispanic or Latino or Spanish origin Middle Eastern or North African Multi-Racial White Some other race
- Select - Female Male
- Select - Attention Deficit Disorder (ADD/ADHD) Autism Spectrum Disorder – Asperger’s Syndrome Autism Spectrum Disorder –Autistic Disorder Autism Spectrum Disorder –Childhood Disintegrative Disorder Autism Spectrum Disorder –Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) Autism Spectrum Disorder –Rett Syndrome Behavioral Disorder Blindness/Visual Impairment Cancer (please specify) Cardiovascular Disorder (please specify) Central Nervous System (Brain & Spinal Cord) Disorders – Absence of Corpus Callosum Central Nervous System (Brain & Spinal Cord) Disorders – Encephalopathy Central Nervous System (Brain & Spinal Cord) Disorders – Hydrocephalus Central Nervous System (Brain & Spinal Cord) Disorders – Microcephalus Central Nervous System (Brain & Spinal Cord) Disorders – Periventricular Leukomalacia Central Nervous System (Brain & Spinal Cord) Disorders – Shaken Baby Syndrome Central Nervous System (Brain & Spinal Cord) Disorders – Spinal Cord Injury (please specify level) Central Nervous System (Brain & Spinal Cord) Disorders – Spinal Cord Tumor (please specify level) Central Nervous System (Brain & Spinal Cord) Disorders – Traumatic Brain Injury Central Nervous System (Brain & Spinal Cord) Disorders – Other (please specify) Cerebral Palsy – Unspecified Cerebral Palsy – Ataxic/Monoplegia Cerebral Palsy – Ataxic/Diplegia Cerebral Palsy – Ataxic/Hemiplegia Cerebral Palsy – Ataxic/Quadriplegia Cerebral Palsy – Dyskinetic/Monoplegia Cerebral Palsy – Dyskinetic/Diplegia Cerebral Palsy – Dyskinetic/Hemiplegia Cerebral Palsy – Dyskinetic/Quadriplegia Cerebral Palsy – Mixed/Monoplegia Cerebral Palsy – Mixed/Diplegia Cerebral Palsy – Mixed/Hemiplegia Cerebral Palsy – Mixed/Quadriplegia Cerebral Palsy – Spastic/Monoplegia Cerebral Palsy – Spastic/Diplegia Cerebral Palsy – Spastic/Hemiplegia Cerebral Palsy – Spastic/Quadriplegia Chromosome Abnormality – Down Syndrome Chromosome Abnormality – Klinefelter Syndrome Chromosome Abnormality – Trisomy 13 Chromosome Abnormality – Trisomy 18 Chromosome Abnormality – Turner Syndrome Chromosome Abnormality – Deletion (please specify) Chromosome Abnormality – Translocation (please specify) Chromosome Abnormality – Other (please specify) Cleft Lip/ Palate Connective Tissue Disorder – Ehlers-Danlos Syndrome Connective Tissue Disorder – Marfan Syndrome Connective Tissue Disorder – Osteogenesis Imperfecta Connective Tissue Disorder – Other (please specify) Deafness/Hearing Impairment Developmental Delay Endocrine Disorder (please specify) Epilepsy/Seizure Disorder (please specify) Gastrointestinal Disorder (please specify) Intellectual Delay Leukodystrophy/other Myelination Disorder (please specify) Metabolic Disorder (please specify) Mitochondrial Disorder Mood Disorder/Mental Illness (please specify) Movement Disorder (please specify) Muscular Dystrophy – Becker Muscular Dystrophy – Congenital Muscular Dystrophy – Duchenne Muscular Dystrophy – Emery-Dreifuss Muscular Dystrophy – FSHD Muscular Dystrophy – Limb-Girdle Muscular Dystrophy – Other (please specify) Other Genetic Disorder (please specify) Other Muscular Disorder – Hypertonia Other Muscular Disorder – Hypotonia Other Muscular Disorder – Torticollis Other Muscular Disorder – Other (please specify) Other Neurologic Disorder (please specify) Other Neuromuscular Disorder (please specify) Orthopedic Disorder – Clubfoot Orthopedic Disorder – Congenital Amputation (please specify) Orthopedic Disorder – Scoliosis Orthopedic Disorder – Traumatic Amputation (please specify) Orthopedic Disorder – Other (please specify) Paralytic Syndromes – Hemiparesis Paralytic Syndromes – Hemiplegia Paralytic Syndromes – Paraplegia Paralytic Syndromes – Quadriparesis Paralytic Syndromes – Quadriplegia Paralytic Syndromes – Other (please specify) Pulmonary Disorder (please specify) Skull and Facial Bone Disorders – Craniosynostosis Skull and Facial Bone Disorders – Plagiocephaly Skull and Facial Bone Disorders – Other (please specify) Speech/Language Disorder (please specify) Spina Bifida – Closed Neural Tube Defect Spina Bifida – Spina Bifida Occulta Spina Bifida – Meningocele Spina Bifida – Myelomeningocele Spinal Muscular Atrophy – Type I Spinal Muscular Atrophy – Type II Spinal Muscular Atrophy – Type III Spinal Muscular Atrophy – Type IV Stroke – Ischemic (blood clot) Stroke – Hemorrhagic (brain bleed) Other Diagnosis not otherwise listed (please specify) Spina Bifida - Unspecified
School or Program Child Attends
Parent First Name
Parent Last Name
How did you hear about Variety?
- Select - Friend Family Member Medical Professional Advertisement Social Media Other Vendor
- Select - Crawford, MO Franklin, MO Gasconade, MO Iron, MO Jefferson, MO Lincoln, MO Perry, MO Pike, MO St. Charles, MO St. Francois, MO St. Louis City, MO St. Louis, MO Ste. Genevieve, MO Warren, MO Washington, MO Bond, IL Calhoun, IL Clay, IL Clinton, IL Fayette, IL Greene, IL Jersey, IL Macoupin, IL Madison, IL Marion, IL Monroe, IL Montgomery, IL Randolph, IL St. Clair, IL Washington, IL
Primary Phone Number
See the instructions and diagram below to correctly measure your child for a helmet. Once you've measured your child's head, select the correct helmet size.
To find your size, wrap a flexible tape measure around the largest portion of your head—about 1 in. above your eyebrows.
Or, wrap a string or ribbon around your head, then measure the length of string with a straight-edge ruler or yardstick.
Bike Style and Size
How to select the correct bike size?
12” Bike – typically 3 to 5 Years or 37–42" tall
16” Bike - typically 4 to 6 Years or 42–48" tall
20” Bike – typically 5 to 9 Years or 44–56" tall
26” Bike - typically 12 years to Adult or 60"+ tall
Note: Training wheels are provided for 12" and 16" bikes only.
Select a bike for your child:
Please indicate if your child will need training wheels:
Training wheels are only available for 12 inch and 16 inch models.
RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT
EMERGENCY MEDICAL CARE - PHOTOS
My name is
I am the guardian of
I am responsible for the child and have authority to sign the releases below on behalf of myself, the child and the child’s family.
Variety the Children’s Charity of St. Louis (Variety) is sponsoring Bikes for Kids.
The child and/or child together with me and/or the child’s family wishes to participate in the event. There is no charge for participation.
The event may include transportation to and from the site by private car and/or other transportation means. It will include entry and exit and activities at the site. In connection with the event Variety and/or its sponsors may provide favors or gifts, including toys.
I acknowledge that participation in the various phases of the event, including post-event activities, will involve the risk of injuries and damages including but not limited to injuries or damages resulting from car accidents and/or falls, playing with gifts and toys and other mishaps. Injuries and/or damages may include death, personal injury, property damages, loss of services and other losses.
I understand that unless I sign this release on behalf of myself, the child and the child’s family, Variety will not allow me, the child or the child’s family to participate in the event.
In order to participate in the event, on behalf of the child, myself, and the child’s family, I therefore release the officers, directors, agents, affiliates, sponsors, volunteers, successors, assigns and employees of both Variety and the site, and I release all drivers and owners of all vehicles involved in the transportation of the participants, (collectively “the released parties”), from all liability for injuries or damages resulting from activities connected with the event, and use of gifts and toys received at the event,
to the extent those injuries or damages are result of negligent acts.
I further agree to hold the released parties harmless and to indemnify them against any claims brought against them by third parties due to my actions and/or the child’s actions.
On behalf of the child and myself, I thus hereby release the released parties from all claims for damages or injuries for negligent acts connected with the event. I exclude from the release grossly negligent acts, intentional acts, and acts done with malfeasance.
I understand this release is quite broad, but I nevertheless accept its terms.
--EMERGENCY MEDICAL CARE RELEASE--
Should the need arise in the course of the event, I hereby give authority to all representatives of the Variety staff and the site to provide reasonable emergency medical care to the child and/or to me. I release all claims for injuries or damages incurred by me or the child in connection with the delivery of such care in good faith. This release is also a condition of participation in the event.
Emergency Medical Release
I understand this release is quite broad, but I nevertheless accept its terms.