ࡱ>    !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrtRoot EntryZ O28dsCONTENTS CompObjVSPELLING ck preferred size: Small Medium Large XLarge XXLarge Volunteer Signature: Date:      (Parent/Guardian sign if volunteer is under 18 years of age.) Name:      Signature: Name:      Phone:      Relationship      Name      Mailing Address      DOB      Home Telephone      Office Telephone      Primary Insurance Provider      Secondary Insurance Provider      Primary Policy Number      Secondary Policy Number Family Physician      Address      Telephone      In the event of injury or emergency connected with the BRAIN Squared Project 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):      FORMTEXT      # #      # ####Date of Birth:# FORMTEXT      # ####Mailing address:# FORMTEXT      # ####Work phone:#,:rt*,Dl@xxxxxxxxxxxxxxN8 "v "" "A"PS * " "|2'( g " "  "v "" ""14"4" 4""PS  4"@@Bvx| V X Z \ t (468Zfhjfrjl(2"'( 3 g  4"4"4" "|4" "4"CHNKWKS @TEXTTEXTFDPPFDPPFDPPFDPPFDPPFDPPFDPPFDPP FDPCFDPC"FDPCFDPC$FDPCFDPC&FDPCFDPC(FDPCFDPC*FDPCFDPC,STSHSTSH.STSHSTSH/bSYIDSYID~4SGP SGP .5INK INK 25BTEPPLC 650BTECPLC f5@FONTFONT5BRAIN SQUARED PROJECT - 2011 Volunteer Registration Form . If the Volunteer is under 14 years of age, you must be accompanied by a parent/guardian, who must also fill out an application. Please list the following parent/guardian information so we may cross-reference your application with their application: Emergency Contact Return this form no later than May 15, 2011 to: Linda Young 1033 Vincent Avenue Schenectady, NY 12306 Pg. 1 of 2 Rev (04.01.2011) BRAIN Squared Project - 2011 Volunteer Confidential Medical and Contact Information I agree to have this information released in the event of an emergency/injury connected with the BRAIN Squared Project. OR I choose not to provide any medical information. Signed: Date:     Note: The medical information you provide is optional. Volunteer medical forms will be put in a sealed envelope and held by the Volunteer Director during the day of the RIDE and will be opened only in the case of medical emergency. After the RIDE all volunteer medical forms are destroyed and not maintained. We encourage all riders to provide this information, particularly if you have a medical condition about which you wish to inform our paramedics in case of injury or medical difficulty during the BRAIN Squared Project. Pg. 2 of 2 Rev (04.01.2011) Full Name: (as it appears on your Social Security card - No Nicknames)           Date of Birth:      Mailing address:      Work phone:      Home phone:      E-mail:      Cell phone:      Employer:      Expertise that could assist BRAIN Squared      ALL EVENT UPDATES WILL BE SENT BY E-MAIL T shirt size Please cheL6BDFNZ\^|JV&246$&(*4@Zfv ,.0D"4" 4"4"!DPRT*8FH\jxzfhj4" "|4"4" 4" 8:tzn>>vlf  "|2 "|$$ 086 "|$$ 08*$$ 08, $$ 080 $$ 08  "PSF " ""1$$ 08."@ " ""1$$ 08vxzV \ t  &(h^..0 "$$ 082 "$$ 08*$$ 080 $$ 08 "|0 "$$ 08, $$ 08 2 "PS$$ 084(28XZdj&dfprhlxtBBBBB2 "!$$ 08*$$ 082 "$$ 08, $$ 08<46@FLNX^z|HJTV $&06"*2r2 "!$$ 08, "!$  08, $$ 08;24>@XZdftv *0BDNT(*68DHZ\hjvzn2 "!$$ 080 "!$$ 08, $$ 08 *$$ 08, $$ 08 TSH4:@FLRX^OIC3 Bullet Text Table textInside AddressAttention Line Bullet List 1NTSHhRt4b@t6v4 "" "|$ 08  *q"$F ""  ""1$$ 08"PS   *q4"4 "|" "|$ 08 "v ""  *q4 "" "|$ 08 "PS *q"*" "|$ "B " "|""PS *q2'( 4"*" "|$ & " ""PS *q4" *" "|$ "B " "|""PS *q2'( 4"< "" "|$$ 084"0 " "| *q2'( |00 "!" "|$ 02 " "| *q2'( |4"< "" "|$$ 084"  *q4"< "" "|$$ 084""PS *q4"4 "" "|$ 088  *q"< "" "|$$ 084"0 " " *q2'( 0**  !"#$%&'()*ttD (2"$&(*,lONT 2HArialTahomaKGaramondLTimes New Roman'!:;<=>?@ABCJIJabWXYZ[\]^_`abcdefghijklm< "g"l""`"l""""|""\K""""LE ""3_""H" "t" "" "" "9" "BPRNTWNPRFRAMFRAMTITLTITL]TDOP DOP  Z O2Quill96 Story Group Class9qy`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y`y``Py`V`\y`cy`y`y`y`y`y`y`y`y`y`y`