City of Wichita - Police Forms Application for Bicycle Clinic

Sunday, July 20, 2008 :: Currently 75 degrees in Wichita

City Hall
455 N. Main
Wichita, Kansas 67202

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Police Department

City of Wichita > City Offices > Police Department > Police Forms > Application for Bicycle Clinic

Application For Bicycle Clinic

Please fill in all areas of the form below:

Child's Name

Street Address

City

State

Zip/Postal Code

Home Phone

Work Phone

Parent/Guardian Name

Age of Participant

Email Address

List Family Doctor below:

List Hospital Preference below:

List any handicaps or physical ailments below:

I will provide a helmet for my child:

Yes No

Please list your date preference below:

Please pick your 1st choice date:

Please pick your 2nd choice date:

Please pick your 3rd choice date:

AGE GROUP	DATE	AREA	BUILDING	ADDRESS
2008 Bicycle Clinic Schedule
6 - 8	June 5	North	Jackson Elementary School	2717 N. Woodlawn
9 - 11	June 6	Central	Pleasant Valley Elementary School	2000 W. 29^th St. N.
6 - 8	June 9	West	Northwest High School	1220 N. Tyler Road
9 - 11	June 10	West	Northwest High School	1220 N. Tyler Road
6 - 8	June 16	South	Anderson Elementary	2945 Victoria
9 - 11	June 17	South	Enterprise Elementary	3605 S. Gold
6 - 8	June 18	South	Linwood Elementary	1654 S. Hydraulic
9 - 11	June 19	South	Linwood Elementary	1654 S. Hydraulic
6 - 8	June 23	East	Central Christian Church	2900 N. Rock Road
9 - 11	June 24	East	Central Christian Church	2900 N. Rock Road
6 - 8	June 25	East	Seltzer Elementary	11660 E. Lincoln
6 - 8	June 30	East	Curtis Middle School	1031 S. Edgemoor
9 - 11	July 1	East	Curtis Middle School	1031 S. Edgemoor
6 - 8	July 7	North	Stucky Middle School	4545 N. Broadview Circle
9 - 11	July 8	North	Stucky Middle School	4545 N. Broadview Circle
9 - 11	July 9	South	White Elementary	5148 S. Kansas
6 - 8	July 10	West	McCollom Elementary	1201 Waddington
9 - 11	July 11	West	McCollom Elementary	1201 Waddington
6 - 8	July 22	West	West High School	820 S. Osage
9 - 11	July 23	West	West High School	820 S. Osage

You will be notified of your assigned date of attendance, via mail within 7 days!

Please Read Carefully

The undersigned parent and/or guardian of the above named applicant, and for such applicant and for myself, my heirs and assigns, hereby releases, discharges and forever holds harmless the City of Wichita, it servants and agents, and the Wichita Police Department and all members thereof from any and all damages or claims for personal injury or otherwise which may arise by reason of the above applicant's receiving bicycle training from the Wichita Police Department.

The Signature part of this form will be signed by the parent/guardian
at check-in time, on location.

Please be patient after hitting the submit button, process can take up to 15 seconds.