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Glass Casa Bicycle Waiver & Agreement Form
Please complete all required fields. By filling out this form and providing your information you are agreeing to the terms of this agreement/waiver and terms and conditions. Once you have added all the Riders you will be directed to the agreement/waiver and terms and conditions signature page. Thank You
The Team At Glass Casa
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Name
*
First
Last
Cell Phone
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Person Address
Property Name
*
The property name you have booked
Reservation Number
*
Please enter your reservation number
Email
*
Date of Birth
*
Enter your date of birth
As The Responsable Part I Certify That all Riders Are 16 Years or Older And If Not Will Be Supervised By an Adult
*
Yes
Additional Riderr 2
*
select yes or no
No
Yes
To add additional drivers select yes
Name
*
First
Last
Date of Birth
*
Enter your date of birth
I Certify That Rider Is 16 Years or Older And If Not Will Be Supervised By an Adult
*
Yes
Additional Rier 3
*
select yes or no
No
Yes
Select yes to add additional drivers
Name
*
First
Last
Date of Birth
*
Enter drivers date of birth
I Certify That Rider Is 16 Years or Older And If Not Will Be Supervised By an Adult
*
Yes
Additional Rier 4
*
select yes or no
No
Yes
Select yes to add additional drivers
Name
*
First
Last
Date of Birth
*
Enter drivers date of birth
I Certify That Rider Is 16 Years or Older And If Not Will Be Supervised By an Adult
*
Yes
Continue to E-Signature
