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Application for Bicycle Helmet

  1. Terms of agreement*
    I agree to receive a bicycle helmet for my child. I will hold the Silverton Police Department, the City of Silverton and its representatives harmless from any and all claims of injury or damage from wearing of the bicycle helmet. I will direct all inquiries regarding equipment, warranty or service to the manufacturer or its authorized representative.
  2. Parent signature
    __________________________________________________
  3. Print name
    _________________________________________________
  4. For office use only
    I gave the above named individual a bicycle helmet for their child to wear. I explained that the helmet must be worn when on a bicycle, skateboard, scooter, roller blades/ skates or anything that moves faster than a person can walk.
  5. Silverton Police Representative
    ______________________________
  6. Leave This Blank: