Personal Registration

Please complete the information below and enter your full name exactly as you would like it to appear on your certificate. If your name is too long, you may abbreviate your middle name and/or second surname.

Note: Please do not write in the first two fields; these will be filled in by the administration.

Por favor, complete la siguiente información y escriba su nombre y apellidos exactamente como desea que aparezcan en su certificado. Si su nombre es demasiado largo, es posible que abrevie su segundo nombre y/o su segundo apellido.

Nota: Por favor no escriba en los 2 primeros campos, los mismos serán llenados por la administración.

Certificate Number

Certification Number

Event Date

Country – State

First Name *

Last Name *

Date of Birth

Age

Nationality

Profession

Address (Area and City Only)

Mobile Phone

Email *

Instagram

How Long Have You Been Practicing the Program?

Gender

T-Shirt Size

Height

Weight

Who Was or Is Your Instructor/Tutor (Coach)?

CPR (Cardiopulmonary Resuscitation) Certification/Test

Did You Complete the Musical Counting Workshop?

Do You Have a Stationary Bicycle?

Authorization

By signing this form, I authorize Powerbike USA to use the following personal information:

My image, including photographic, cinematic, and electronic (video) images.
My voice, including audio and video recordings.

I hereby grant Powerbike USA, its subsidiaries, licensees, successors, and assigns the right to use, publish, and reproduce, for any and all purposes, my name, photographs of me in film or electronic (video) format, audio and video recordings of my voice, and printed and electronic copies of the information described in sections (1) and (2) above, in any and all media, including but not limited to broadcast and cable television and the Internet.

This authorization includes the use of such materials for display, distribution, promotion, advertising, sales, press conferences, meetings, hearings, educational conferences, brochures, and other printed or electronic media.

This permission extends to all languages, media, formats, and markets now known or hereafter developed. This authorization will remain in effect unless revoked by me in writing.

I AGREE I DO NOT AGREE

Waiver and Release

I declare that I am in good health and physically able to participate in physical activity. I am not aware of any medical condition that could be dangerous or aggravated by physical exercise.

I agree to inform Powerbike USA staff if I develop or have any medical condition and, if requested, provide medical clearance confirming that I can exercise safely.

I assume full responsibility for my health and safety when using Powerbike facilities and equipment, whether independently or under instruction, and while participating in any class activity.

I AGREE I DO NOT AGREE

By signing this form, I certify that the information I have provided is true and accurate. I ALSO UNDERSTAND THAT ANY FALSE STATEMENTS OR INTENTIONAL OMISSIONS MAY BE GROUNDS FOR DISQUALIFICATION.