ࡱ> e4   !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdfghijklmnopqrstuvwxyz{|}~Root EntryZ O2`[JW5CONTENTS Object 69YnL - NGW NGWContentsI  Jersey Program: To reduce our jersey costs and direct more funds to helmet distribution and the mission of BRAIN SQUARED PROJECT , each rider who meets their fund-raising minimum is given a BRAIN SQUARED-Logo Jersey at no charge, only in their first year of the BRAIN SQUARED Project ride. The funds for the purchase of the BRAIN SQUARED-Logo jersey are provided by the contributions of our Corporate Partners, Sponsors and Contributors. Riders will not automatically get a new, complimentary BRAIN SQUARED Logo Jersey each year, but are asked to use the jersey received in all subsequent rides. Donation amounts for additional jersey(s) cited above is an  estimate and the actual costs will vary depending on the volume of jerseys we purchase in any given order/year. Jersey Sizing Chart . BRAIN SQUARED PROJECT Ride 2011 Waiver of Negligence and Complete Release of Liability This is an important legal document, please read carefully before signing below. I certify I am physically fit, have sufficiently trained for participation in this event, and have not been advised otherwise by a qualified medical person. I acknowledge a bike ride carries with it the potential for serious injury, property loss, and death. The risks include, but are not limited to, those caused by terrain, water and road conditions, weather, condition of rider s equipment, vehicular traffic, actions of participants, volunteers, spectators, and/or producers of the event, and lack of hydration. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THE BRAIN SQUARED PROJECT RIDE 2011 I hereby take action for myself, my executors, administrators, heirs and next of kin, successors and assigns as noted below. a) RELEASE AND DISCHARGE the BRAIN SQUARED PROJECT & NYSATSB, sponsors of this event, event dirCHNKWKS TEXTTEXTeFDPPFDPPhFDPPFDPPjFDPPFDPPlFDPPFDPPnFDPPFDPPpFDPPFDPPrFDPCFDPCtFDPCFDPCvFDPCFDPCxFDPCFDPCzFDPCFDPC|FDPCFDPC~FDPCFDPCFDPCFDPCFDPCFDPCFDPC FDPCFDPC FDPCFDPC FDPCBRAIN SQUARED PROJECT June 8, 2011 Rider Application Form Rider Eligibility  Riders must meet the fund-raising commitments. Our focus of this ride is on providing education and helmets to bike riding children. Rider s Acknowledgement and Acceptance of Commitments to the BRAIN SQUARED PROJECT and New York State Association of Traffic Safety Boards Inc. (nysatsb) In accepting a position as a member of the BRAIN SQUARED PROJECT I understand and agree to the terms noted below. I am capable of and will train for the 70-mile bike ride to keep an average pace of 14 - 17 mph on the flat portions of the ride. I will help NYSATSB in its work to promote children s bike-safety education. I will raise a minimum of 30 helmets for children which in community donations equal to a minimum of $300.00. I give NYSATSB permission to send E-mails to the address given. I also understand that positions in the BRAIN SQUARED PROJECT are limited to 30 riders, and that by accepting a position in the Project I am reserving my place on the team with every intention of completing my obligations. If I am not able to fulfill my obligations and participate in the Project, I will inform the ride committee as soon as possible so that my position can be given to another interested party. If I voluntarily withdraw from the Project after May 1, 2011 I will fulfill my obligation to donate $300.00 to the Brain Squared Project. I do this with the understanding that my late withdrawal from the ride has affected the ability of the ride committee to fill the position I have reserved and will therefore affect the raising of funds for helmet and educational materials for distribution by BRAIN SQUARED PROJECT & NYSATSB. I agree to all of the above. ectors, volunteers, law enforcement, all cities and municipalities in which the event is conducted, and all affiliated organizations, individuals and entities (and all of their respective officers, directors, agents, employees, and members) ( Parties ) from any and all liability, and waive my rights with respect to any and all claims for damages for death, personal injury or property damage, including but not limited to, medical bills, lost wages, pain and suffering, attorney s fees, and court costs, which I may have, or which may hereafter accrue to me as a result of my participation in this event or traveling to this event, even though this liability may arise through no fault of my own, or from the negligence or carelessness on the part of the Parties, from dangerous or defective property or equipment owned, maintained, or controlled by the Parties or because of the Parties possible liability without fault; b) INDEMNIFY AND HOLD HARMLESS the Parties from any and all liabilities or claims made by other individuals or entities as a result of my actions during The Event, and in any other activities connected with The Event in which I may participate; c) UNDERSTAND, ACKNOWLEDGE, AND AGREE that my name, photograph, voice, or likeness may be used by the Parties and/or their licensees. I consent to and authorize in advance such use and waive any rights of privacy and/or publicity I may have in connection therewith. I hereby consent to receive medical treatment that may be deemed advisable in the event of injury, accident, and/or illness during the Event. I understand weather, emergencies, or other issues of public safety may cause cancellation or postponement of this event. I hold the Parties harmless should such cancellation or postponement occur, and I understand no contributions, payments, or expenses will be refunded. I hereby give my consent to the organizers of BRAIN Squared Project and their agents or representatives, to transport my bicycle(s) and do hereby release the Parties from any claims for damage to my bicycle during transport, including scratches to paint, broken components, changes in the tuning of components, any or all damage, or theft. I will inform said representatives of any special instructions for my bicycle. I understand if any provision of this Waiver of Negligence and Complete Release of Liability is invalid, illegal, or unenforceable under any applicable statute or rule of law, it is to that extent to be deemed omitted. The remainder of this Waiver of Negligence and Complete Release of Liability shall be valid and enforceable to the maximum extent possible. I certify that I have read, understand, and agree to this Waiver of Negligence and Complete Release of Liability. BRAIN SQUARED PROJECT 2011 Confidential Medical Information I agree to have this information released in the event of an emergency/injury connected with the ride OR I choose not to provide any medical information. Signed_________________________________ Date__     ___________________________ Note: The medical information you provide is optional. Rider/Volunteer medical forms will be put in a sealed envelope and held by the BRAIN SQUARED PROJECT Director during the day of the event and will be opened only in the case of medical emergency. After the event all rider medical forms are destroyed and not maintained. We encourage all riders and volunteers to provide this information, particularly if you have a medical condition about which you wish to inform our paramedics in case of injury or medical difficulty during the event. Bike and Rider Certification Please complete the form below and submit with your ride application. The BRAIN SQUARED PROJECT is open to all riders regardless of bicycling experience. Novice Riders will participate in the Novice Rider Program during the training ride in April. This program is used to classify and/or train first-year riders to make sure they will have the ability, equipment, and riding skills to be able to successfully participate in and complete the BRAIN SQUARED PROJECT ride. Experienced riders will work with the Novice Riders to develop and improve riding distance and skill level to enable them to confidently ride with the main group. Unless you are an experienced bicyclist, we strongly recommend riding a road-bike for the BRAIN SQUARED PROJECT Ride rather than a hybrid or mountain bike. If you are planning on riding a mountain or hybrid bike, we strongly urge you to use slick tires - tires without treads. The following information must be completed by all first-year riders. For the safety of all riders, Have their bicycle certified as being in good condition and capable of being ridden the 60+ miles. You must contact the Director of the Rider Training Program, Scott Neff, at (518) 944-1973 or by e-mail at sneff@nycap.rr.com For Committee Use Only Page # of 5 (Rev: 12.01.2010) Office use only: Received q Jersey form q Name/ID Tag q Liability Waiver q Medical Form Date Received Name #     Date of Birth (mm/dd/yyyy)      Age on Day of Ride      Mailing address (Street, city, state, zip code) #     Telephone #(Work)      #(Home)      (Cell)      E-mail #(Primary)      (Alt 1)      (Alt 2)      ALL UPDATES AND BULLETINS WILL BE BY E-MAIL # YES, I would like information on how my employer can help sponsor the BRAIN SQUARED PROJECT. My employer or organization is supporting me with a Corporate Contribution directly for my Poster-Raising minimum: # Full # Partial # Matching Funds Signed Date#     2011 BRAIN SQUARED T-Shirt, & Name Tag Information Form ALL Riders must fill out the information in this box for Event T-Shirt and Name Tag. Name:      Date:      Initials: T-shirt size: Small Medium Large X-Large XX-Large Please PRINT the name you prefer to have on your Name Tag:      Note: Depending on available space we may need to abbreviate your name. 2011 BRAIN SQUARED Logo Jersey Size Form Note: Fill out this next section, complete additional copies of this form for each rider if participating as a team ride. I have: tried on a sample used the sizing chart a 2010 BRAIN Squared jersey My Jersey size is (check one) Number of Jerseys      Men s Women s Small Medium Large X-Large XX-Large XXX-Large Jersey requests submitted after May 15, 2011 may not be filled in time for the ride. Riders will be issued t-shirts and jerseys prior to ride Optional: I would like to make a special donation of $55 to help NYSATSB offset the expense of my jersey. I will make a special donation of $55 per jersey to get additional jersey(s) for myself this year. Donations for jerseys by riders will allow NYSATSB to use more of our funds for helmet distribution and the mission of the BRAIN SQUARED PROJECT. Number of Jerseys____ x $55.00/ea. = $ ____.___ Total Check #_____ First Name: #     and Middle Initial Last Name #     Street Address #     City #     State, Zip Code #     Home Telephone #     Birth Date #     Signature Date #     Name #     Mailing Address #     DOB #     Home Telephone #     Office Telephone #     Insurance Provider #     Policy Number #     Family Physician #     Address #     Telephone #     In the event of injury or emergency connected with the ride please notify the individual noted below. Name #     Relationship #     Address #     Telephone #     Secondary Contact Name      Relationship      Address      Telephone      Medical Conditions I am aware of, or am being treated for # Asthma # Seizure Disorder # #     # Bronchitis # #     # #     # Diabetes # #     # #     # High Blood Pressure # #     # #     # History of Heart Disease # #     # #     Medications currently being taken: #     Please also list any allergies (including medications you are allergic to):      Name      Years Bicycling      Assess your cycling skill level. Are you: Novice Rider- one who does not know or may be unsure how to use their bike gears; has not ridden with an organized group; may or may not be aware of their riding speed; has not ridden more than 15 - 20 miles per ride. We offer the Novice Rider training on  how to ride a bike and ride in a large group. Recreational Rider- one who has no long-distance (over 30-miles per ride) bicycling experience; has not ridden in a group ride; may not be aware of their riding speed; and has not ridden Intermediate Rider- one who has several years experience riding; knows how to use their bike gears; can maintain a pace greater than 18 mph on the flats for extended distances - assuming light headwind; has ridden more than 30-miles in a single ride; has experience riding in a group pace-ride for distances longer than 30-miles; knows proper group pace-ride etiquette, hand signals. Advanced Rider- a rider who has participated in organized bicycle races of over 50-miles in length maintaining a sustained pace of greater than 20 mph. 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