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Wheelie Nation – Risk Acknowledgement, Health Declaration & Participant Consent

Participant Information

Full Name

Date of Birth

Email Address

Mobile Number

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone Number

1. ABOUT THE EXPERIENCE

Wheelie Nation provides a supervised motorcycle wheelie machine experience using a motorcycle secured to a trailer-mounted training apparatus. The rear wheel operates on a roller, allowing the motorcycle’s front end to rise and lower while the motorcycle remains attached to the apparatus.

The experience involves motorcycle controls, moving machinery, changes in motorcycle angle, vibration and physical effort. A harness or restraint system is used as part of the setup. The machine, restraints, protective equipment and supervision reduce risks but cannot eliminate them.

This experience does not qualify me to perform wheelies independently or demonstrate that I can safely perform them on a road or another motorcycle.

Event Details

Event Name

Event Location

Participation Date

Waiver & Consent

[Insert your waiver text here. You can update this text to include your specific legal requirements.]

I have read and understood the activity description and risk warning, including the risk of serious injury, permanent disability or death.

I have honestly disclosed relevant previous injuries, medical conditions and current symptoms, and will tell the operator if anything changes before my session.

I understand that submitting this form does not provide medical clearance or automatic approval to participate.

I agree to follow the safety briefing, operator instructions, protective equipment requirements and operating rules.

I am not affected by alcohol, drugs or medication that would make participation unsafe.

I am participating voluntarily and have had the opportunity to ask questions.

Permissions (Optional)

Untitled checkboxes field

Participant Signature

Sign here

Date of Signature

2. IMPORTANT RISK WARNING

Participation can cause injury, including serious injury, permanent disability or death.

Risks include, but are not limited to:
• Sudden or unexpected movement, lifting or lowering of the motorcycle, jolting, loss of balance or incorrect use of the controls.
• Slipping or falling while approaching, mounting, riding or dismounting the motorcycle or using the trailer ramps and platforms.
• Contact with the motorcycle, apparatus, restraints, trailer or surrounding objects.
• Entanglement, crushing, pinching, friction injuries or contact with rotating wheels, rollers, chains and other moving components.
• Pressure, rubbing or strain caused by the harness or restraints.
• Burns from hot motorcycle components, and exposure to noise, vibration or exhaust fumes where applicable.
• Equipment malfunction or failure, including motorcycle, mechanical, electrical, restraint or attachment faults.
• Sprains, strains, bruising, cuts, fractures, dislocations, and head, neck, back, spinal or nerve injuries.
• Aggravation or recurrence of previous injuries, pain, medical conditions or disabilities.
• Dizziness, fainting, fatigue, panic or other physical or psychological reactions.
• Risks arising from participant error, other people’s actions, weather or site conditions.

I understand that injuries may occur despite supervision and safety precautions, and that this list cannot identify every possible risk.

3. PREVIOUS INJURIES AND HEALTH DECLARATION

Do you have any current or previous injury, medical condition, disability, recent surgery, pregnancy, or medication effect that could affect your participation or be aggravated by this activity? (Examples include neck, back, spinal, shoulder, arm, wrist, hand, hip, knee or ankle injuries; fractures; nerve injuries; restricted strength or movement; heart or breathing conditions; seizures; fainting; balance problems; and conditions affecting your ability to understand instructions or operate the controls.)

A
B

Are you currently experiencing pain, weakness, dizziness, illness or another symptom that could affect your ability to participate?

A
B
I have disclosed relevant health information honestly and to the best of my knowledge. I understand that this activity may aggravate a previous injury or condition. If I am unsure whether participation is suitable for me, I will seek advice from an appropriately qualified health professional before participating.

I understand that Wheelie Nation operators cannot provide medical clearance. Completing this form does not mean I have been approved to participate. I must discuss any disclosed condition with the operator before my session.

7. REQUIRED AGREEMENT CHECKBOXES

I have read and understood the activity description and risk warning, including the risk of serious injury, permanent disability or death.

9. PRIVACY AND RECORDS

Wheelie Nation collects your participant details, relevant health disclosures and signature to assess participation, manage safety, record consent and respond to incidents.

Relevant records may be provided to emergency responders, our insurer or professional advisers where reasonably necessary, or where required by law. Health information will not be used for marketing.

For privacy enquiries, contact: sales@wheelienation.com.au.

I consent to the collection and use of relevant health information for these purposes.

I have honestly disclosed relevant previous injuries, medical conditions and current symptoms, and will tell the operator if anything changes before my session.

I understand that submitting this form does not provide medical clearance or automatic approval to participate.

I agree to follow the safety briefing, operator instructions, protective equipment requirements and operating rules.

I am not affected by alcohol, drugs or medication that would make participation unsafe.

I am participating voluntarily and have had the opportunity to ask questions.