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Ride for Missing Children Greater Capital District
Friday, September 24, 2010
Rider Application Form

Registration Deadline Dates
- Returning Riders June 1 2010
- New Riders June 1 2010
- Sister Riders July 1 2010
Official Use Only: Received

Jersey Form
First-Year Rider Form
"License Plate" name
Liability Waiver
Medical Form
Name
(as it appears on your Social Security Card)

Date of Birth (mm/dd/yy)

Age on day of ride

Mailing Address (Street, City, State, Zip)

Telephone

(work)(home)(cell)
Email (all meeting updates and bulletins will be by e-mail)

(primary) (alt)
Nominated by


High School Rider

Grade School Name
College Rider
Year School Name
Employer


Yes, I would like information on how my employer can help sponsor the Ride for Missing Children GCD.
My employer or organization is supporting me with a Corporate Contribution directly for my Poster-Raising minimum: Full Partial Matching Funds
My fund-raising will be done in full or in part by a payroll deduction.

Amount:

United Way SEFA Other
I am interested in participating in the "Adopt-A-School" program
(Schools Committee will contact you after acceptance)
I am a First Year Rider Returning Rider Fifth Year Rider Tenth Year Rider
If this is not your first ride, what is your home ride:
Albany Buffalo Finger Lakes Rochester Utica
Years in the Ride: '08 '09 '10

Rider Eligibility – Riders Must be age 15 by the day of the Ride (September 24, 2010). Riders will be accepted based on the date of submission of their application, with preference to Returning Riders who have met their previous poster (fund)-raising commitments. While the focus of our mission is not on bike riding, we must set certain minimum limits of bicycle-riding ability for the safety of all Riders.

RIDER’S ACKNOWLEDGEMENT AND ACCEPTANCE OF COMMITMENTS TO THE RIDE FOR MISSING CHILDREN AND NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN/MOHAWK VALLEY/GCD
In accepting a position as a member of the Friends of Missing Children riders for the Ride for Missing Children GCD,

I understand and agree to the terms noted below.


- I will be age 15 by the day of the Ride (September 24, 2010)

- I am capable of and will train for the 100 to 110-mile bike ride to keep an average pace of 14 - 17 mph on the flat portions of the ride.

- I will help NCMEC in its work to promote child-safety education.

- I will raise a minimum of 2,000 posters of missing children in community donations equal to a minimum of $500.00.

- I give NCMEC/Mohawk Valley/GCD permission to send E-mails to the address given.

- I have provided my social security number on the Waiver. Since this program involves children, I agree NCMEC may use my social security number to conduct a background check. (Which is why we need your SSN). Riders who have been convicted of abduction of a child or a sexual offense or exploitation of a child will be disqualified from any activity related to The Ride.

- I also understand that positions in the
Ride for Missing Children GCD are limited to 100 riders, and that by accepting a position in the Ride I am reserving my place on the team with every intention of completing my obligations. All First-Year Riders are required to attend a minimum of 4-training rides prior to the Ride and all returning riders must attend a minimum of 2 training rides.

- If I am not able to fulfill my obligations and participate in the Ride, 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 Ride after August 14, 2010 I will fulfill my obligation to donate $500.00 to the NCMEC Poster Distribution program. 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 to distribute posters of missing children by NCMEC/Mohawk Valley.


I agree to all of the above.

_________________________________________________________________________________
Signature / Date


Parent of a Minor Child (at least 15 years of age by the day of the Ride):

_________________________________________________________________________________
Signature / Date


Please return this form by mailing to:
The RIDE for Missing Children
Greater Capital District
P.O. Box 233
Pattersonville, NY 12137

!! SCROLL DOWN FOR REMAINING FORMS - THIS SPACE FOR PRINTING PURPOSES



First Year Rider - Bike and Rider Certification

First-year riders please complete the form below and submit with your ride application.
The Ride for Missing Children GCD is open to all riders regardless of bicycling experience. Novice Riders will participate in the Novice Rider Program during the training rides in July. 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 Ride for Missing Children. First-year riders who are not already experienced cyclists will do their first training ride with the Novice-Rider Training Group while more experienced cyclists may attend the main training rides. Participants in the Novice-Rider Training Group will train separately from the main group of riders until it is verified they can keep the Ride Pace. Experienced riders 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 Ride for Missing Children 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,
First-Year Riders must:

- Have their bicycle certified as being in good condition and capable of being ridden the 100+ miles.

- Attend at least four (4) training rides, and be verified by the Director of Rider Training as being able to do the Ride at a pace of 14 - 17 mph.

If you have any extenuating circumstances which make it impossible for you to participate in a minimum of 4-training rides you must contact the Director of the Rider Program, Scott Neff, at (518) 944-1973 or by e-mail at sneff@nycap.rr.com

Name

Years Bicycling:

Assess Your 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, or been able to keep up the pace in a “C” ride in the Mohawk Valley Bicycling Club rides or similar organization.
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, and is familiar with bike safety; is a “B” or “fast C” rider in the Mohawk Valley Bicycling Club rides or similar organization.
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; has ridden in a group pace-ride of over 50-miles; and is an “A” or “Fast-B” rider in the Mohawk Valley Bicycling Club rides or similar organization.

For Committee Use Only      
Training Rides Attended
(Dates)
 
 
 
 
This rider and bicycle have been verified by my as being able to participate in the Ride for Missing Children GCD.
Please initial and date Corrine Kennedy, Director
Rider Registration

 
Scott Neff, Director
Rider Training

 



100-Mile Ride for Missing Children GCD - 2010
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 RIDE FOR MISSING CHILDREN GCD 2010 (“the Ride”).

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 National Center for Missing & Exploited Children (“NCMEC”), sponsors of this event, event directors, 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 Ride, and in any other activities connected with The Ride 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 Ride.

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 The Ride 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.

Signatures below
(Parents/Guardian sign if rider is under 18 years of age, and at least 15 by the date of the Ride)
Please give your name Home Phone Number:Birth Date:(mm/dd/yy)


Street Address:


City:State: Zip:



_________________________________________________________________________________

Signature / Date


2010 RIDE T-Shirt, Ride Pin & Name Tag Information Form
ALL Riders must fill out the information in this box for Ride T-Shirt, Ride Pin, and Name Tag.

Name:

Date: (mm/dd/yy)

Initials:

Name as you prefer on your name tag: Name: (if different than above)
Note: Depending on available space we may need to abbreviate your name.

Choose One: First-Year Rider (fill out next section)

A Returning Rider who did not yet receive my Ride-Logo Jersey (fill out next section)

A Returning Rider purchasing another Ride-Logo Jersey (fill out next section)

A Returning Rider who
does not need a Ride-Logo Jersey (have on from previous Ride)
 
T-Shirt Size: Small Medium Large X-Large XX-Large
 
Are you a...? Fifth-Year Rider Tenth-Year Rider


2010 RIDE Logo Jersey Size Form
Note: Fill out this next section ONLY if you are a First-Year Rider, a Returning Rider who does NOT already have a Ride Jersey, or if you want to PURCHASE another Ride-Logo jersey.

Name:

Date: (mm/dd/yy)

Initials:

Name as you prefer on your name tag: Name: (if different than above)
Note: Depending on available space we may need to abbreviate your name.

I have: Tried on a sample Used the sizing chart I have a Voler jersey
 
My Jersey Size:

# of Jerseys:

Men's Women's

Small Medium Large X-Large XX-Large XXX-Large
   
Jersey requests submitted after July 3, 2010 may not be filled in time for the Ride. Riders will be issued t-shirts and jerseys at the September rider/volunteer meeting. Sample jerseys will be available at the rider/volunteer rider meetings for you to try on.
 
Optional:
I would like to make a special donation of $55 to help NCMEC-NY/MV 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 NCMEC/NY/MV to use more of our funds for missing child poster distribution and the mission of NCMEC/NY/Mohawk Valley.
 
# of jerseys   x $55.00/ea. =   total Check # Charge - fill out credit card form

 
 

Ride-Logo Jersey Program: To reduce our jersey costs and direct more funds to missing children posters and the mission of NCMEC-NY/Mohawk Valley, each Rider who meets their fund-raising minimum is given a Ride-Logo Jersey at no charge, only in their first year of the Ride. The funds for the purchase of the Ride-Logo jersey are provided by the contributions of our Corporate Partners, Sponsors and Contributors. Riders will not automatically get a new, complimentary Ride 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
The Jersey Committee recommends that you select your jersey only after trying on one of our samples. If you are unable to attend one of the Rider Meetings or Jersey Try-On Sessions, the chart provided may be helpful to you. The following sizing chart is taken from the Voler website.

Please note: Voler jerseys run small, if in doubt we recommend that you go one size up from the chart recommendations.

Women's Sizing Chart

Size

Size

Waist

Weight

Height

Chest

x small

0-2

22-24

95-115

5'2" & under

30-32

small

4-6

25-27

110-120

5'1" to 5'5"

32-34

medium

8-10

27-29

120-145

5'4" to 5'8"

34-36

large

12-14

30-32

140-165

5'7" to 5'11"

36-38

x large

16

33-35

160-185

5'10" & over

39-41

xx large

20-22

36-38

190-205

5'10" & over

41-43

xxx large

24-26

39-40

210-225

5'10" & over

43-45


Men's Sizing Chart

Size

Waist

Weight

Height

Chest

x small

26-29

100-120

5'5" & under

33-35

small

29-31

120-145

5'4" to 5'8"

35-37

medium

32-34

145-170

5'7" to 5'11"

38-40

large

35-37

170-190

5'10" to 6'2"

40-42

x large

38-41

190-220

6'1" to 6'5"

42-44

xx large

42-45

220-250

6'3" & over

44-46

xxx large

46-50

250-260

6'3" & over

46-48


2010 Credit Card Form
Note: Fill out this form ONLY if you want to PURCHASE a Ride-Logo Jersey with your credit card.

Name as it appears on card:

   
Type of Card:

American Express Discover Master Card Visa

Card Number:

Expiration Date:

Amount:

.
 
____________________________________________________________________________
Signature / Date


Ride for Missing Children GCD 2010 - 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.

Name

Date of Birth (mm/dd/yy)

Mailing Address (Street, City, State, Zip)

Telephone

(work)(home)
Insurance Provider:
Policy Number:
Family Physician:
Address:
Telephone:
PRIMARY EMERGENCY CONTACT:
In the event of injury or emergency connected with the ride, please notify the individual below:
Name
Relationship:
Telephone (work)
Mailing Address (Street, City, State, Zip)

SECONDARY EMERGENCY CONTACT:
In the event of injury or emergency connected with the ride, please notify the individual below:
Name
Relationship:
Telephone (work)
Mailing Address (Street, City, State, Zip)


Choose
Asthma
Bronchitis
Diabetes

High Blood Pressure
History of Heart Disease

Seizure Disorder

Other (please list:)
________________________________________________________________________

Signature / Date
Medications currently being taken:

Please also list any allergies (including medication allergies):


Note: The medical information you provide is optional. Rider medical forms will be put in a sealed envelope and held by the NCMEC Director during the day of the Ride and will be opened only in the case of medical emergency. After the Ride all rider 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 Ride.