We ride for those who died

2013 Registration Form

Dear Member,

On behalf of the Police Unity Tour, Chapter VII, Southern California, We would like to welcome you to our organization, which is the proud sponsor of the National Law Enforcement Officer's Memorial Fund. (N.L.E.O.M.F.) located in Washington D.C. The Chief Executive Officer, Patrick Montoure organized the Police Unity Tour in May 1997 with the hope of bringing public awareness for officers who have died in the line of duty. The goal was to have police officers ride bicycles from New Jersey to Washington D.C. over three day period. Each respective member was required to raise a certain amount of money to participate in this event. Currently the fee to ride in the Tour is $1,800.00. A $150.00 non-refundable membership fee is required with your application. This may appear to be a lot of money to participate but there are considerable expenses, which are incurred as a result of this venture i.e. hotels, insurance, supplies etc.

It gives me great pleasure to be part of the Police Unity Tour and I am looking forward to working with everyone. This is a unique organization whose members volunteer a considerable amount of time to a worthy cause and work in a Team atmosphere. The Southern California, Chapter VII Executive Board maintains the right to rescind membership privileges to those who fail to participate or meet their financial obligations. The Police Unity Tour is a 501C3 non-profit organization ID No. 22-3530541.

At present Southern California, Chapter VII will entertain applications for two hundred and fifty members. Individuals may also elect to become at-large members by paying the membership fee and volunteering their time in an effort to raise awareness to the National Law Enforcement Officers Memorial.

Proud Sponsor of the National Law Enforcement Officers Memorial

To Become a Member Please fill out the Form below.
Registration fee is NOW $150.
This is a non-refundable registration fee.


Registration Form
I am a : (check one) NEW Member of Chapter 7: Returning Member of Chapter 7:
NEW MEMBERS ONLY: As a new member of Chapter 7 Southern California I understand that I will be required to have training ride evaluations and that failure to complete these or any other training requirements may cause me to forfeit my roster spot for the 2013 Tour. I have read and understand the training requirements for NEW members: YES : NO :
I will be participating as a : (check one) Rider: Motor: Support:

First Name: Last Name:

Sex: Male Female	E-mail:	Cell Phone #:
Street Address: City: State: ZIP:

Driver's License Information:
License #:	State:	Expiration:
Endorsements:

Law Enforcement Affiliation:
Department:
Please check the box that applies:
Active Officer: Retired Officer: Survivor of Officer Killed in Line of Duty: Civilian Member of Police Agency :
Street Address: City: State: ZIP:
Work #:

Medical Insurance Information
DOB:	Blood Type:
Medical Insurance Carrier:	Group:	ID #:

Current Medications: ( Please List all )
Allergies (Medications, Foods, Stings. etc.)
Operations or Serious Injuries in the LAST 3 YEARS: (i.e. Cardiac issues, Fractures, Strokes, Diabetic Emergencies, etc.)
Under care of Physician for following:
Any medical information that may be helpful in the event of an Emergency:
Emergency Contact:
Emergency Contact Name: Relationship:
Street Address: City: State: ZIP:
Home Phone #:	Cell Phone #:
Alternate Emergency Contact:
Alt. Emergency Contact Name: Relationship:
Street Address: City: State: ZIP:
Home Phone #:	Cell Phone #:

Medical Information and Emergency Medications I understand and agree that if any of the information requested above should change prior to the start of the Tour on May 9th, it is my responsibility to notify Police Unity Tour Chapter 7 Southern California of such changes. I am also aware that emergency medications that I may need while riding, such as inhalers and epipens must be labeled and checked in with the follow vehicle.
I have read and understand the above statement regarding my medical information and emergency medications: YES NO
Hold Harmless Agreement I hereby acknowledge that I have applied and may be accepted to participate in the Police Unity Tour, Inc. I understand that this bicycle ride is being organized by the Police Unity Tour Inc. I acknowledge that it has been recommended that I undergo a complete physical examination by a licensed physician prior to participation in the event and prior to any and all of the training sponsored by the Police Unity Tour Inc. I understand that there are risks of injury and / or death inherent in such bicycle trips and training. I agree that the Police Unity Tour, Inc. or Chapter 7 shall not be responsible to my estate, my surviving spouse, children or any other family member or me. Thus on account of any injury and or death I may sustain which indemnify and hold the Police Unity Tour Inc., Chapter 7 and all its members harmless for any and all claims due to my injury and / or death resulting from any cause under any circumstances which arises from my participation in the Police Unity Tour. This includes any and all activities, whether on or off the road or bicycle, that are associated with the Police Unity Tour. I further agree that should I be asked to leave the ride by any authorized tour member for any reason, such as I am in physical distress, physically unable to continue, proceeding at a pace that is detrimental to the tour, or in any other way considered to be a danger to myself or other tour members, that I shall immediately comply with that order ceasing my activities and proceed directly to the nearest tour support vehicle. I understand that should I fail to follow the direction of any authorized personnel during the tour or refuse any offer of medical or physical assistance, I shall be ejected from the tour, removed as a member and shall proceed at my own risk and indemnify and hold the Police Unity Tour Inc., Chapter7 and all its members harmless for any and all claims made as a result of my actions and/or refusal to comply.
I have read and agree with the Hold Harmless Agreement: YES NO
No Alcohol Policy The Police Unity Tour represents federal, state and local law enforcement nationwide. As members of the Police Unity Tour, we realize our greater responsibility to the brotherhood, our profession and what we represent as ambassadors to the National Law Enforcement Officers Memorial. For that reason, as a Member of the 2013 Police Unity Tour, I will not consume alcohol during the Tour operating hours nor shall I possess or consume alcohol on the grounds of the National Law Enforcement Officer’s Memorial. I understand that any violation of the aforementioned policy will result in my immediate ejection from the tour.
I have read and understand the NO ALCOHOL policy: YES NO
Fundraising Obligations I understand that if I am selected to participate in the 2013 Police Unity Tour, I will be obligated to raise at least $1800.00 and meet all fundraising deadlines set forth by the Chapter. I further understand that missing a fundraising deadline could result in being removed from the Chapter 7 roster. I further understand that all donations are non-refundable and non-transferable even if I do not participate in the event. I also understand that the Police Unity tour is a not-for-profit organization under section 501(c)(3) of the Internal Revenue Code and agree that while fundraising for my participation in the tour I must comply with all Federal, State and Local laws governing such fundraising.
I have read and understand my fundraising obligations: YES NO
Privacy Cause I understand that my name, photograph, voice or likeness may be used by the Police Unity Tour, the National Law Enforcement Officers Memorial Fund and its and their sponsors, beneficiaries, licensees, affiliates, officers, agents and employees to broadcast, telecast, print account or use any other account in any medium for publicity or promotional purposes. I hereby waive any right I may have to inspect and approve the final reproductions or any copy that may be used in connection therewith or the use to which it may be applied and I hereby release, discharge, and agree to hold Police Unity Tour and the National Law Enforcement Officers Memorial Fund harmless from all liability by virtue of any such use, including without limitation any claims of libel or invasion of privacy or any legal or equitable claims I may have now or in the future relating thereto, and I understand that I will not benefit financially from any use thereof.
I have read and understand the above privacy cause: YES NO

I have answered YES for the five (5) previous questions and I am typing my name in the box below to represent my signature understanding my commitment and responsibility for the 2013 Police Unity Tour.
Signature: Date: What word do you see:

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, 2013***

2013 Registration Form

Registration Form

Medical Insurance Information