We ride for those who died

2010 Police Unity Tour Medical Form

Email:
Full Name (Last, First MI): Rider/Support #:
Address: City: State: ZIP:
DOB: Last Tetanus:
Insurance: Policy#: Group:
Current Medications: ( Please List all )

Last Physical: Height: Weight: Blood Type:
Operations or Serious Injuries in the LAST 3 YEARS: (i.e. Cardiac issues, Fractures, Strokes, Diabetic Emergencies, etc.)
Allergies (Medications, Foods, Stings. etc.)
Currently Under Physician Care for:
Physician Name: Telephone #:
Emergency Contact Name: Telephone #: Relationship:	Alternative Contact Name: Telephone #: Relationship:

Do Your Religious Beliefs Prohibit Any Medical Procedures? Yes No
If Yes, Please Explain:
If there is any medical information that you believe our Medical Team should know about in the event of an Emergency, please indicate it here:

Rider Standards and Obligations I hereby acknowledge that the POLICE UNITY TOUR , INCORPORATED bicycle tour to Washington, D.C. is a serious strenuous physical activity and team effort in which I will be required to make certain milestones in order to keep the Tour on schedule, and that I will be one of many riders on the Tour. I also understand and agree that I will be subject to strict rider standards and will be obligated to obey Authorized Tour Personnel, including, but not limited to, the RideMarshals, Support Staff and Executive BoardMembers during the ride. I agree, that should I be asked to leave the r ide by author ized T our per sonnel for any reason, such as a determination that I am in any physical distress, am physically unable to continue or are continuing at a pace detr imental to the Tour , or are in any way considered to be a danger to myself or other T our r ider s, that I shall immediately comply with that order by ceasing my T our activities and proceeding directly into the nearest T our Suppor t V ehicle. Failure to follow the direction of author ized per sonnel dur ing the T our , or refusal of any offer of medical or physical assistance shall be grounds for removal from the T our . I hereby agree to participate in the POL ICE UNITY TOUR , INCORPORATED bicycle tour to Washington, D.C. (May 10-12, 2010) and attend the NATIONAL LAW ENFORCEMENT OFFICERS MEMORIAL CANDLELIGHT VIGIL (May 13, 2010). In consideration of being permitted to participate in any way in the Police Unity Tour, Inc. sponsored activities, I, the undersigned, freely acknowledge and realize the dangers of participating in the activities and fully assume all risks including, but not limited to, collision with pedestrians, vehicles, other riders, and/or fixed or moving objects, the negligence of other riders, sponsors, support personnel or drivers, and dangers arising fromfalls, road surface, equipment failure, inadequate safety equipment, weather conditions, as well as the possibility of physical and/or mental trauma (or injury). I understand that the route requires bicycling on public roadways in all weather conditions, and that cyclists have been hospitalized and/or killed due to collisions. I further agree that I will bear all expenses incurred in any such collision. I realize the activities require physical conditioning and I represent that I am in sound medical condition and that it has been recommended that I undergo a complete physical examination by a licensed physician prior to participation. I have no physical or medical impediment, which would endanger others or myself. I understand and agree that a situationmay arise during an activity, whichmay be beyond the control of the sponsors, promoters, or organizers and agree to ride so as not to endanger either others or myself. I will wear an ANSI or SNE L L certified helmet when riding a bike during the Police Unity Tour, Inc. sponsored rides. I accept responsibility for the condition and adequacy of my bicycle. I understand if I leave the route, I am no longer on the ride. I waive, release, discharge for myself, my heirs, executors, administrators, legal representatives (including successors), any and all rights and/or claims which I have, may have or may hereafter accrue to me against the sponsors and promoters of the Police Unity Tour, Inc., or other sponsors or affiliated organizations and their respective agents, officers, members and/or employees for any and all damages, injuries or claims which may be sustained by me directly or indirectly arising out of my participation in the activities. The above agreements and representations are my express understandings of the risks and I assume these voluntarily and freely without coercion or duress. This agreement may not be modified orally andmay not be waived in any respect.
I have read and under stand the above RIDER STANDARDS AND OBLIGATIONS AGREEMENT and agree to same therefore placing my signature on this form:
Signature: Date:

Proud Sponsors of the National Law Enforcement Officers Memorial
“ WE RIDE FOR THOSE WHO DIED”

***Each participant must raise $1,800 in donations by March 31st, 2011***