Passenger Application Form

Cycling Without Age Napier Trust Passenger Application

Applicant name *

First name

Last name

Your preferred first name

Your Address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Date of Birth *

Email address *

Home phone *

Mobile phone

Emergency Contact: Name, relationship and phone number please *

Do you have a Power of Attorney (POA) or Guardian? *

Yes

Contact details of your POA or guardian please.

Email address of POA

Please let us know if you use a

Cane or nothing

Electric wheelchair

Non electric wheelchair

Walker

Will you be able to get in and out of trishaw unassisted? *

Yes

Are you able to sit up unaided? *

Yes

Do you need a companion to ride with you? *

Yes

Do you have any medical condition that may affect you while you are riding, such as vision or hearing loss, osteoporosis, heart condition etc.? *

Yes

DNR Operating *

Please indicate if you have have instructions "not to resuscitate".

Please expand or provide any additional information that you think may be useful for your Pilot to know.

First Contact date *

Please expand on "Other" if ticked above

By word of mouth, friends, passengers or ........?

Cycling Without Age Napier Trust (CWA Napier), is creating intergenerational experiences by providing Trishaw rides for elders piloted by volunteers. Will you abide by Cycling Without Age policies and procedures as laid out in the Passenger Handbook?

YES *

In consideration for permission to be a passenger, I have received, read and understand the CWA Napier Passenger Handbook, and agree to abide by their procedures and I attest that all of the information I have provided is accurate and complete. I understand and agree that acceptance into the programme is entirely at the discretion of CWA Napier.

Passenger Waiver of Liability
I, the above named and undersigned, am the Passenger taking part in the CWA Napier programme.

• I understand and agree that there may be inherent risks associated with participation in this activity, that my participation is voluntary and that I am physically fit enough to participate in the activity.
• I accept all responsibility for my participation including the possibility of personal injury, death, property damage of any kind notwithstanding that the injury, loss may have been contributed to or occasioned by the negligence of CWA Napier and its coordinators, officers, directors, employees, members, volunteers, agents, assigns, legal representatives and successors.
• I acknowledge that cover may be available under The Injury Prevention, Rehabilitation and Compensation Act 2001.
• I do hereby indemnify and hold harmless: CWA Napier and its coordinators, officers, directors, employees, members, volunteers, agents, assigns, legal representatives and successors and any and all business associates and partners involved in the above noted activity and each of them, their owners, officers and employees hereby waiving all claims for damage now or in the future arising from any loss, accident, injury or death which may be caused by or arise from participation of the individual named herein during this event; and agree to assume all risks for the activity noted above that the individual named herein has agreed to participate in.

My signature acknowledges that I am over the age of 18 and had sufficient time to read and understand this waiver. I understand and agree to the conditions stated here in this waiver and that they are binding on my heirs, next of kin, executors, administrators and successors.

Signature *

Date *

If you have indicated you have a Power of Attorney, we will contact them on your behalf (with your permission) after you submit this application form

I give my permission for CWA Napier to contact my Power of Attorney