POLICE MEMORIAL RIDE by qfa60885

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									                                       POLICE MEMORIAL RIDE
                                              Medical History Form
             A current medical history form must be completed each year. Previous forms are destroyed annually.

Name of Applicant:

Date of Birth:                                            Blood Type:

Name of Medical Insurance Carrier:

Group Number:                                             ID Number:


                                                  Medical History
Current Medications:


Allergies:

Operation or Serious Injuries in the Last Three Years:

Under the care of a physician for the following:


If there is any medical information that you believe may be helpful for us to know in the event of an
emergency, please indicate “yes” and list the information. If necessary, use the back of the form.
YES          NO



Emergency medications that may be needed while riding, such as inhalers and epi pens must be
labeled and checked in with the lead vehicle.

                                               Emergency Contact
Name of Contact:                                                              Relationship:

Address:

City:                                 State:                                  Zip:

Home Phone Number:                    Business Phone Number:                  Cell Phone Number:


                                       Alternate Emergency Contact
Name of Contact:                                                              Relationship:

Address:

City:                                 State:                                  Zip:

Home Phone Number:                    Business Phone Number:                  Cell Phone Number:


I understand and agree that if any of the information requested above should change prior to the start of
                  th
the ride on May 10 it is my responsibility to notify the Police Memorial Ride of such changes.
Print Applicant Name:                               Print Witness Name:

Applicant Signature:                  Date:               Witness Signature                             Date:
                                            POLICE MEMORIAL RIDE
                                                        Application Form

Name:
                                                                                                 Male          Female
Home Address:

City:                                                            State:                          Zip:

Group Name:                                                      Cell phone Number:              Home Phone Number:

Email Address:

Drivers License Number:            State:                   Expiration:                Endorsements:

           Applicants for support and motors please attach a copy of the front and back of your driver’s license.

                                             Law Enforcement Affiliation
Name of Department/Organization:

Address:

City:                                     State:                                      Zip:

Phone Number(s):


I have participated in         previous rides.
I will be participating as a: Rider       Motor             Support          EMS

                                              HOLD HARMLESS AGREEMENT
I hereby acknowledge that I have applied and may be accepted to participate in the Police Memorial Ride. I understand that this
bicycle ride is being organized by the Greater Cincinnati Police Historical Society. 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 Greater Cincinnati Police Historical Society. I understand that there are risks of injury and/or death
inherent in such bicycle trips and training. I agree that the Greater Cincinnati Police Historical Society 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 Greater Cincinnati Police Historical Society 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 Memorial
Ride. This includes any and all activities, whether on or off the road or bicycle that is associated with the Police Memorial Ride.

I further agree that should I be asked to leave the ride by any authorized ride member for any reason, such as I am in physical
distress, physically unable to continue, proceeding at a pace that is detrimental to the ride, or in any other way considered to be a
danger to myself or other ride members, that I shall immediately comply with that order ceasing my activities and proceed directly to
the nearest ride support vehicle. I understand that should I fail to follow the direction of any authorized personnel during the ride or
refuse any offer of medical or physical assistance, I shall be ejected from the ride, removed as a member, and shall proceed at my
own risk and indemnify and hold the Greater Cincinnati Police Historical Society 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 understand the above Hold Harmless Agreement and agree to same therefore
placing my signature on this form:
Print Applicant Name:                                           Print Witness Name:

Applicant Signature                         Date                Witness Signature                         Date


           Each participant must raise at least $500.00 in sponsorship prior to the ride.
A $25.00 non-refundable application fee must be submitted with the completed application packet.

                                    Please charge my application fee to the following:
                                                                   Credit Card
Method of Payment (circle)      Card / Check #   Expiration Date
                                                                   Verification Code
Amex Visa MasterCard Discover
Check
Signature

								
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