Bicycle Lesson confirmation

Client Name(Required)
MM slash DD slash YYYY


This document affects your legal rights:

Read carefully before signing.

  1. ACTIVITIES AND ASSOCIATED RISKS: I have chosen to participate in the following Activities: (hereinafter referred to as “the Activities”), which is organized by Ask Learn Go, LLC. (hereinafter referred to as “ALG”). I understand that:

the Activities are hazardous, and I may be exposed to inherent dangers and hazards, including but not limited to some of the following (depending on the nature of the Activities): falls, fractures, concussions, dangerous or unanticipated weather, overexertion, overheating, injuries from my lack of fitness or conditioning, hypothermia, hostile or aggressive wildlife, venomous or disease-carrying animals or insects, communicable diseases, exposure to allergens which could cause life-threatening reactions, death, equipment failures, losing control of or crashing the bike, traffic, collisions with moving or parked vehicles or other obstacles, road and/or mountain bike trail hazards (e.g., sewer gratings, gravel, logs and debris), failure to wear a helmet and/or other protective equipment, and negligence of others;

as a consequence of these risks and other risks associated with the Activities that may not be listed here, I may be seriously ill, hurt, disabled or may die from the resulting injuries, and my property may also be damaged;

hospital facilities, qualified medical care, and emergency medical evacuation may be delayed, limited, or unavailable during portions of the Activities; and

ALG assumes no responsibility for providing medical care during the Activities, and I will have to pay for any medical care and/or evacuation that I incur.

In consideration of the permission to participate in the Activities, I agree to the terms contained in this document.
  1. ASSUMPTION OF THE RISKS: I hereby freely assume the inherent risks as well as any other risks not listed that are part of these Activities, and any harm, injury, illness, or loss that may occur to me or my property as a result of my participation in the Activities or during any transportation to or from the Activities—including any injury, illness, or loss caused by the negligence of ALG, its employees, agents and officers, its contractors, and other Activities participants. I also understand that any equipment that I provide or may borrow or rent from ALG or any other provider I use at my own risk and that any such equipment is provided without any warranty about its condition or suitability.
  2. RELEASE OF LIABILITY: I hereby RELEASE ALG, its employees, agents, officers, and contractors, the providers of any equipment used in the Activities, land owners, municipal or governmental providers of use permits, and their respective employees, officers, and directors (“the Released Parties”) FROM ALL LIABILITIES, CAUSES OF ACTION, CLAIMS AND DEMANDS that arise in any way from any injury, illness, death, loss or harm that occur to me or to any other person or to any property during the Activities or in any way related to the Activities, including during transportation to or from the Activities. This RELEASE includes claims for the negligence of the Released Parties and claims for strict liability for abnormally dangerous activities. This RELEASE does not extend to claims that Washington law does not permit to be released by Agreement. I also agree NOT TO SUE or make a claim against the Released Parties for death, injuries, loss or harm that occur during the Activities or are related in any way to the Activities. including attorneys’ fees and costs of defense, which the indemnified parties may incur arising out of the negligence, error, omission, or other cause arising out of or resulting from the use of the premises and/or physical therapy services provided by ALG., The obligation to indemnify and hold harmless specifically includes claims, liabilities, demands, suits, causes of actions or proceedings arising from the negligent acts or omissions of the indemnified parties.
  3. INDEMNIFICATION HOLD HARMLESS AND DEFENSE: I promise to INDEMNIFY, HOLD HARMLESS AND DEFEND the Released Parties (defined in Section 3) against any and all claims to which Section 3 of this Agreement applies, including claims for their own negligence. I also promise to INDEMNIFY, HOLD HARMLESS AND DEFEND the Released Parties against any and all claims for my own negligence, and any other claim arising from my conduct during the Activities. In accordance with these promises, I will reimburse the Released Parties for any damages, reasonable settlements and defense costs, including attorney’s fees, that they incur because of any such claims made against them. I agree that in the event of my death or disability, the terms of this Agreement, including the indemnification obligation in this Section, will be binding on my estate, and my personal representative, executor, administrator or guardian will be obligated to respect and enforce them.
  4. AGREEMENT TO FOLLOW DIRECTIONS: I agree to follow the rules for the Activities provided to me and to follow directions given to me by the leaders of the Activities.
  5. INDEPENDENT CONTRACTORS: I acknowledge that ALG has no control over and assumes no responsibility for the actions of any independent contractors providing any services for the Activities.
  6. USE OF MY LIKENESS: I understand that during the Activities I may be photographed or videotaped. To the fullest extent allowed by law, I waive all rights of publicity or privacy or pre-approval that I have for any such likeness of me or use of my name in connection with such likeness, and I grant to ALG and its assigns permission to copyright, use, and publish (including by electronic means) such likeness of me, whether in whole or part, in any form, without restrictions, and for any purpose.
  7. SEVERABILITY: I agree that the purpose of this Agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by FLORIDA law. I agree that if any portion or provision of this Agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the Agreement.
  8. APPLICABLE LAW AND FORUM: This Agreement shall be construed in accordance with the laws of the state of FLORIDA, without any reference to its choice of law rules. I agree that any dispute arising from this Agreement or in any way associated with the Activities shall be brought only in the Superior Broward County (201 SE 6th St, Fort Lauderdale, FL 33301), or in the U.S. District Court (299 E Broward Blvd STE 108, Fort Lauderdale, FL 33301), and I agree to the jurisdiction and venue of those courts for any such dispute.


If the participant is a minor, signature of the parent or responsible adult is required below:

In consideration of the minor child being permitted to participate in the Activities, I accept and agree to the full contents of this Agreement. I certify that I have the authority to sign on behalf of the minor child and to make decisions for the minor child regarding these Activities. I also agree to RELEASE, HOLD HARMLESS, INDEMNIFY AND DEFEND the Released Parties (defined in Section 3) from all liabilities and claims that arise in any way from any injury, illness, death, loss or harm that occurs to the minor child during the Activities or in any way related to the Activities. This includes any claim of the minor and any claim arising from the negligence of the Released Parties. I understand that nothing in this Agreement is intended to release claims for liabilities that Florida law does not permit to be excluded by Agreement.


Use of Website

You acknowledge that the information on the Website is provided ‘as is’ for general information only, and is subject to change without notice. It is NOT intended to provide healthcare advice, and should NOT be relied upon as a substitute for consultations with qualified health professionals who are familiar with your or your child’s individual health needs. ASK LEARN GO, LLC., including its shareholders' officers, directors, employees, agents, and contractors, MAKES NO WARRANTIES OF ANY KIND WHATSOEVER REGARDING THIS WEBSITE OR SERVICES, INCLUDING BUT NOT LIMITED TO ANY WARRANTY OF ACCURACY, COMPLETENESS, CURRENCY, RELIABILITY, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, OR ANY WARRANTY THAT THESE PAGES, OR THE COMPUTER SERVER WHICH MAKES THEM AVAILABLE, ARE FREE OF VIRUSES OR OTHER HARMFUL ELEMENTS, AND SUCH WARRANTIES ARE EXPRESSLY DISCLAIMED.

No Refund for Services Rendered

You agree that all monies paid for services rendered by ALG are non-refundable. Please note that AskLearnGo cannot guaranty compliance or the ability to master the skills we teach. A participant/rider will be considered having mastered bicycle riding if they can independently travel 5+ yards.


I acknowledge that I can request HIPAA documentation from ASK LEARN GO and its' staff.



10500 Oak Meadow Ln.

Lake Worth, FL 33449.


The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the Patient, significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

We have prepared this "Summary Notice of HIPAA Privacy Practices" to explain how we are required to maintain the privacy of your health information and how we may use and disclose your health information. A Notice of HIPAA Privacy Practices containing a more complete description of the uses and disclosures of your health information is available to you upon request.

We may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations:

  • TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers.
  • PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review.
  • HEALTH CARE OPERATIONS include managing your Electronic Medical Record to facilitate diagnostic medical consultations with participating physicians, as well as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service.
  • We may also create and distribute de-identified health information by removing all references to individually identifiable information.
  • We may contact you to provide information about our services or other health-related services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.


You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the ASK LEARN GO Privacy Officer:

  1. You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment and health care operations.
  2. You may also request that we limit our disclosures to persons assisting your care. We will consider your request but are not required to accept it.
  3. You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail.
  4. Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a nominal fee for copying and mailing.
  5. If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add the missing information. Under certain circumstances, we may deny your request, such as when the information is accurate and complete.
  6. You have a right to receive a list of certain instances when we have used or disclosed your medical information. If you ask for this information from us more than once every twelve months, we may charge you a fee.

Privacy Policy Statement

  • We require persons or organizations that represent or assist us in servicing your data stored on this website to be kept confidential.
  • We may share your personal information with third parties. You can request to maintain your personal information private at any time by emailing us at
  • We require employees to protect your personal information and keep it confidential.
  • By you sharing your username and password, you agree to provide access to that person; hence ALG is not held liable for the actions of 3 party individuals/companies that you share access with.


  • You agree to not hold Ask Learn Go, LLC or any of its' employees or affiliates liable or responsible for exposure to or contraction of COVID-19 during lessons/interactions with Ask Learn Go, LLC or other Ask Learn Go customers.
  • The following information must taken into consideration prior to determining treatment needs amidst the COVID-19 pandemic.Individuals with weak or compromised immune systems are at the greatest risk for contracting COVID-19. This includes people with conditions such as, but not limited to, diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current medical condition. We ask that you disclose any condition that may compromise your immune system. Please be advised that lessons may be rescheduled in the interest of the health and safety of our customers and our team.If you have been exposed to COVID-19 or are experiencing any signs or symptoms associated with the virus, it is essential that you share this information with an Ask Learn Go team member prior to receiving treatment.