Learn to Ride / Traffic Skills 101 - Please talk with someone at Pedal America before registering.

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* 1. Contact Information

Last Name

First name

Street Address, apt #

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Gender

Male

Female

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* 3. Height

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* 4. Do you have a bicycle?

Yes

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* 5. What is the approximate longest distance in miles you have ridden in one day during the past year? (TS 101 Students only)

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* 6. Which course are you interested in taking?

Learn to Ride

Traffic Skills 101

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* 7. Check the kind of riding you do or would like to do.

Local recreational

Long distance

Commute to work

Fitness riding

Very little

None, I'm interested in learning to ride

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* 8. What do you hope to gain from this course?

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* 9. (FOR SUMMER LTR STUDENTS ONLY) Do you have any physical or emotional conditions that you feel might limit your participation in this course? Even if you have a mild fear of falling, please let us know. Offer as much detail as possible, or write "none."

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* 10. TS 101 Course Fee(s): Please enter all that apply to your intended course of study

	TS 101 - Part 1 (Not Available)	TS 101 Part II (NOT AVAILABLE)	Learn To Ride Only - Use Drop Down Menu
Learn To Ride - Now Scheduling (Two-hour session required for first lesson)	Learn To Ride - Now Scheduling (Two-hour session required for first lesson) TS 101 - Part 1 (Not Available) menu	Learn To Ride - Now Scheduling (Two-hour session required for first lesson) TS 101 Part II (NOT AVAILABLE) menu	Learn To Ride - Now Scheduling (Two-hour session required for first lesson) Learn To Ride Only - Use Drop Down Menu menu
Part I only - Classroom session (Saturday, November 11th)	Part I only - Classroom session (Saturday, November 11th) TS 101 - Part 1 (Not Available) menu	Part I only - Classroom session (Saturday, November 11th) TS 101 Part II (NOT AVAILABLE) menu	Part I only - Classroom session (Saturday, November 11th) Learn To Ride Only - Use Drop Down Menu menu
Part I - Classroom session (NOT AVAILABLE)	Part I - Classroom session (NOT AVAILABLE) TS 101 - Part 1 (Not Available) menu	Part I - Classroom session (NOT AVAILABLE) TS 101 Part II (NOT AVAILABLE) menu	Part I - Classroom session (NOT AVAILABLE) Learn To Ride Only - Use Drop Down Menu menu
Part II only - On-bike session (NOT AVAILABLE)	Part II only - On-bike session (NOT AVAILABLE) TS 101 - Part 1 (Not Available) menu	Part II only - On-bike session (NOT AVAILABLE) TS 101 Part II (NOT AVAILABLE) menu	Part II only - On-bike session (NOT AVAILABLE) Learn To Ride Only - Use Drop Down Menu menu
Part II - If already completed Part 1 classroom (Not yet available)	Part II - If already completed Part 1 classroom (Not yet available) TS 101 - Part 1 (Not Available) menu	Part II - If already completed Part 1 classroom (Not yet available) TS 101 Part II (NOT AVAILABLE) menu	Part II - If already completed Part 1 classroom (Not yet available) Learn To Ride Only - Use Drop Down Menu menu

Other (please specify)

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* 11. Choose Dates (Subject to availability. We make every effort to accommodate. Confirm specific date and time with instructor before registering).

	Preferred Date	Preferred Time
Learn to Ride	Learn to Ride Preferred Date menu	Learn to Ride Preferred Time menu
Traffic Skills 101 (Nov. 11th at Galway Arms Tavern; 2442 N. Clark, Chicago 60614)	Traffic Skills 101 (Nov. 11th at Galway Arms Tavern; 2442 N. Clark, Chicago 60614) Preferred Date menu	Traffic Skills 101 (Nov. 11th at Galway Arms Tavern; 2442 N. Clark, Chicago 60614) Preferred Time menu

All students should bring a notebook and something to write with. Also, bring something to drink and a small snack. The class will include two 15-minute breaks. We ask students to please bring their bike helmets for learning how to properly adjust them.

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* 12. Release: (Note: Helmets are required for all LTR and TS 101 on-bike participants.) I am aware of the risk of bicycling and otherwise participating in this course and voluntarily assume such risk. In consideration of being permitted to participate in this event: (1) I release for myself, my heirs, and personal representatives, the League of American Bicyclists, Inc., and the respective directors, officers, volunteers, and staff (releasees) from any claim liability, demand, action, and cause of action whatsoever (collectively, "Claim") arising out of or related to any loss, damage or injury (collectively, "Loss"), to myself or my property, that I may sustain in connection with, or arising out of, this event, whether caused by the negligence of the releasees or otherwise; (2) If registrant is a minor, I (as parent or guardian) agree to indemnify and hold harmless each releasee against any claim for any Loss said minor may sustain in connection with or arising out of, this event, and against legal or other expenses incurred by any releasee in connection with defending any Claim by or on behalf of said minor for any such loss, whether caused by the negligence of the releasees or otherwise; (3) I shall obey traffic laws and practice safety in bicycling; and (4) I agree to wear a CPSC or ASNI/SNEL-approved helmet on all bicycle-riding activities at this event.
Enter your name and today's date in the box below as your electronic signature.