Please Print Clearly or Type //Only One Name per Form //Complete Volunteer Waiver Attached

REGISTRATION FORM CHECKLIST – we realize that completing the proper registration forms can be confusing. Please utilize the following checklist to ensure that you have completed the correct paperwork. Thank you for your support!
Communicator Only	 Communicator & SAG Driver	

            Contact Information	

           Contact Information	

            Availability	

           Availability 	

            Housing for Two Day Volunteers	

           Housing for Two Day Volunteers	

            Equipment	

           Equipment	

            Assignment Requests	

           Assignment Requests	

            Bike MS Release and Waiver	

           Driver Information 	

           Pennsylvania Driver Check (PA Drivers ONLY -separate form)	

           Background Check (online form)	

           SAG Commitment	

           Bike MS Release and Waiver	

DEADLINE: AUGUST 15, 2015 – Complete and Return this Form and Waiver to:

Communicators ONLY						Communicator & SAG Driver
Email: N3MSS@mail.com					      	All forms MUST Be Returned Directly to the Society
or MS.EVENTCOMMUNICATIONS@yahoo.com 				Email:Joseph.Selgrade@nmss.org 
Postal Mail: 								Fax: (215) 271-6122
MS Event Communications						Postal Mail:					
C/O Kathy Stafford (AB2LF)						C/ O Joseph Selgrade
128 Stoneham Drive 							30 South 17th Street
Glassboro, NJ 08028							Philadelphia, PA 19103				

To complete these forms online:	http://main.nationalmssociety.org/HAMS
The following forms are also available: 
	Paper Registration .doc Form link: http://www.phil-mont.org/ms150/ 
	Paper Registration PDF Form link: http://main.nationalmssociety.org/communicator-forms
	Paper T-Shirt Support PDF Form link: http://main.nationalmssociety.org/HAMS-support

Everyone MUST Complete the Volunteer Waiver included in this form.
(For insurance reasons, we must have a handwritten signature on file)

CONTACT INFORMATION (Everyone MUST complete)

First Name:					Last Name:					 Call:_______________

Home Address: 						GMRS Call:_________________

City: 				State: 		Zip: 		Birth Date*:	   /	/	 

Email Address:												

Cell: 				                         Home phone: 						

Club Affiliation:__________________________________________________________________

Occupation:					Place of Employment:					

T-Shirt Size:  S   M   L    XL    XXL   XXXL		How long have you been involved with Bike MS? 		   	  

Please describe your prior volunteer experience (include organization names and dates of service):

__________________________________________________________________________________________________________________________________________

      

* Are you 18 or older?
If not, you must complete and return a Minors Waiver. This form will be emailed to you upon submission of your form.

AVAILABILITY(Everyone MUST complete) 

Which Days Can You Help: 		Saturday, October 3              Sunday, October 4              Both Days* 
* SAG drivers MUST register for BOTH DAYS

  

         

	

ASSIGNMENT REQUESTS (Everyone MUST complete - we will try to honor all requests)

Indicate First and Second Choice
                    You Must Attend A Mandatory Orientation in September
        Check Point along the Route                                                                    Event Support Vehicle
   1st  2nd Choice      		                                                            1st 2nd  Choice                       
   □  □ North End Checkpoint                                                       	  □  □ SAG Van Driver/Communicator **                         
   □  □ South End Checkpoint			                    	  □  □ SAG Van Psngr./Communicator 
   □  □ Rest Stop/Lunch Stop                                                                    □  □ Staff/Volunteer Vehicle Driver/Communicator**
   □  □ Last Year’s Location                                                           	  □  □ Other:______________      
□  □ Road Marshaling Position                                            ** All drivers must be at least 25 years of age, be available for 
Provide Last Year’s Mile Markers           			BOTH days, and complete additional paperwork outlined below.
DAY 1_______ DAY 2________      			                   

NOTE: EVENT SUPPORT VEHICLE OPERATIONS REQUIRES A 25 WATT RADIO OR BETTER WITH A 3 Db GAIN 1/2 OR 5/8 WAVE AND A VHF HANDHELD RADIO TO OPERATE WHEN YOU ARE AWAY FROM YOUR ASSIGNED SUPPORT VEHICLE. (Please remember to have a fully charged spare battery for your HT) YOU MUST BE WILLING TO DRIVE VEHICLE, OPERATE RADIO AND FOLLOW DIRECTIONS ALONG THE BIKE ROUTE.

HOUSING (Two Day Volunteers only)

Rooms are limited & available upon request by August 1, 2015 – You MUST be willing to share a room with others:

I would like to reserve a complimentary hotel room in Ocean City: Yes_____ No_____

Roommate Requests – Names & Call Signs: (if none provided, roommates may be assigned for you)
>>>Roommates, please submit all of your forms at the same time<<<

EQUIPMENT 

Bands you can work mobile: 144____ 900____ 440____ GMRS_____ APRS____*
Bands you can work HT:        144____ 900____ 440____ GMRS_____ APRS____* 

* Please list your APRS Radio Gear here:__________________________________________________

PL AND/OR DPL TONE CAPABILITY REQUIRED FOR AMATEUR & GMRS RADIOS.

YOUR RADIOS AND ANTENNAS MUST BE IN GOOD WORKING CONDITION.

DRIVER INFORMATION (SAG & Staff/Volunteer Vehicle Drivers)

YES/NO  I have a valid driver’s license (please circle)  	State you are licensed 			

YES/NO  I have a CDL license (not required)		YES/NO  I have driven a support vehicle for an event before  

What special training or skills do you already have that would prepare you to work as a support vehicle SAG driver?
_____________________________________________________________________________________________

As part of Society Risk Management Policy, all Pennsylvania Drivers driving on behalf of the Society are required to complete the Pennsylvania Request for Driver Information. Link to this form can be found in the email accompanying this document. Please complete and return this form, with the SAG Driver Application, to Joe via email or via fax 215-271-6122.

PENNSYLVANIA DRIVER INFORMATION REQUEST (SAG & Staff/Volunteer Vehicle Drivers - separate document)::

BACKGROUND CHECK (SAG & Staff/Volunteer Vehicle Drivers)

As part of Society Risk Management Policy, all volunteers driving a motor vehicle on behalf of the Society are required to complete a background check. 

If you have volunteered as SAG or truck driver for the Society previously, already submitted your personal information to complete a background check, and your personal information is the same*:

__Yes, all of my personal information is the same and I would like to use this information to complete my background check. 

__No, my personal information has changed.

*so long as personal information has not changed, this form only needs to be completed once, your ‘consent will remain in effect until revoked in a written document signed’ by you.

If you are ‘new’ to driving a SAG or truck for the Society and your role has been confirmed by the lead volunteer,  or your personal information has changed since your last background check, you must complete a background check. Follow the steps below to complete online*.
1.	Click on this Hirease link or copy and paste the following: 
https://backgroundscreening.hiresystem.com/Volunteer/Login.aspx

2.	Log into the system using these credentials (it is case sensitive): 
Client Code:  NMSPHI10 Username: MSDELAWARE2

3.	Click the "Login" button to proceed to the Order - Applicant Information page.

4.	Fill out all required information.  First name, last name, date of birth, current address and your Social Security Number are ALL required in order to complete a background check.  A background check cannot be completed without a Social Security Number.

5.	Click the "Next" button to proceed to the "Order Items" page. 

6.	Click the "Next" button again to proceed to the Checkout page.

7.	Read and sign the Disclosure/Authorization/Release form, which allows a background check to be performed, and then hit the "Checkout" button.

8.	A "Background Screening Order Confirmation" will be emailed to you from tetra@hirease.com.

*If you encounter any issues while completing your background check, or would like to complete over the phone or via paper form, please contact our Human Resources Coordinator, Adia Hagans-Paige at 215-271-1500 ext. 24112.

SAG COMMITMENTS (SAG Drivers Only) By completing & returning this form, you agree to these commitments)

We ask that all drivers commit to both Saturday & Sunday of the Ride. Hours per day dependent on SAG assignment. Route closes at 5pm. All SAG drivers are asked to arrive Saturday to the PATCO Start location in Cherry Hill at 4:30am. 

*Anyone volunteering as a SAG driver MUST be 25 or older.

Complete the appropriate driver paperwork noted below AND sign the attached waiver.

SAG Vehicles consist of a 15 passenger van & 12 ft. box truck. 	
> Box Truck (Cargo): loads & carries bikes, typically leads the pairing, and hosts an amateur radio operator  
> Passenger Van: load people (excellent customer service). Track Inventory # of cyclists and ideal destination.

If you have a ‘vehicle’ preference, please indicate this by circling one: 15 passenger van / 12 ft. box.

If you have a ‘role’ presence, please indicate this by circling one: 15 passenger van / 12 ft. box.

>>We will do our best to honor requests, but cannot guarantee<<

Mandatory Training: Saturday, September 19 from 10:30am-1:00 pm at Chickie’s and Pete’s (Lunch will be provided) on Packer Avenue in South Philly.  1526 Packer Avenue Philadelphia, PA 19145 (click for directions) MARK YOUR CALENDAR!

__ YES, I will be there!	__ NO, but can discuss info prior to the Ride via phone 

SAG COMMITMENTS:: (SAG drivers only - by completing & returning this form, you agree to these commitments)

BIKE MS RELEASE AND WAIVER OF LIABILITY (Everyone MUST complete)
For consideration of participation in the Bike MS: City to Shore Ride 2015, I waive and release the National Multiple Sclerosis Society ("NMSS"), its chapters, directors, officers, administrators, representatives and executors, past and present employees, volunteers, agents, supervisors, participants, all city and state governments, assigns, all sponsors, their representatives and successors and other persons (collectively, the "Releasees"), from any and all claims, liabilities, or causes of action arising out of an injury to me (or my child) and from any and all claims, liabilities, or cause of actions arising from my (or my child's) participation or attendance in this event.

Inherent and Potential Risks
I understand that Bike MS involves strenuous physical activity associated with bicycling long distances potentially over the course of several days. I understand that physical activity, by its very nature, carries with it certain inherent risks. I assume all risks associated with participating in Bike MS relating to the risk of strenuous physical activity, collisions with other riders, or falling off of my bicycle.  I acknowledge that I (or my child) may incur minor injuries, major injuries, and catastrophic injuries including paralysis and death.   I assume all risks from contact with other participants and volunteers, negligent or wanton acts of other participants and volunteers, any defects of conditions of road surfaces (including uneven or wet road surfaces or gravel on the road surface), failure of cyclists, vehicles, and non-participants to observe traffic signals or laws, and the effects of weather including high heat, thunderstorms, lightning, precipitation, cold temperatures, high winds, and/or humidity. 

I acknowledge that my participation in Bike MS may involve an overnight stay and time off of my bicycle where I am still attending the Bike MS event.  I assume all risk for any and all activities in addition to cycling that I (or my child) engage in throughout the entirety of the Bike MS event, including my (or my child's) safety  from the beginning of Bike MS to the conclusion of the event. 

I agree to dress myself (or my child) appropriately as to mitigate risk of physical injury to myself (or my child) including, but not limited to: wearing shoes appropriate for strenuous cycling involved in Bike MS; and dressing in conjunction with the weather. I understand that wearing a helmet that satisfies Consumer Product Safety Commission ("CPSC") standards is a requirement to participate in Bike MS. I agree to wear a helmet that satisfies CPSC standards for the entirety of my participation in Bike MS. 

I agree that the Releasees are not responsible for any personal items or property lost or stolen before, during, or after Bike MS.

Medical Evaluation
I attest that I (or my child) am medically and physically able to participate in Bike MS. If I experience any doubt as to my (or my child's) ability to successfully and safely participate in and/or complete Bike MS, I take full responsibility for consulting a physician. I attest that, if I (or my child) am pregnant, disabled in any way, or have recently suffered an illness, injury, or impairment, I (or my child) should have or did consult a physician prior to participating in Bike MS.

I consent to emergency medical care and transportation in the event of injury to me (or my child) as medical professionals may deem appropriate. This Release extends to any liability arising out of or in any way connected with the medical treatment and transportation provided in the event of an emergency, including, but not limited to, negligent emergency rescue operations.

Voluntary Participation
I am fully aware of the risks connected with participation in Bike MS, whether specifically listed in this Release or not, and I voluntarily elect to participate in Bike MS knowing that this participation involves these risks. I understand that my participation in Bike MS accompanies a minimum fundraising obligation for the benefit of NMSS.

Assumption of Risk, Waiver of Liability, Release, and Covenant Not To Sue
In consideration for being permitted to participate in Bike MS, I voluntarily agree for myself, my family, heirs, assigns, executors, and administrators to the following:

1. TO ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, OR PERSONAL INJURY, INCLUDING DEATH that may be sustained by me (or my child), or any loss or damage to property owned by me (or my child), as a result of participating in Bike MS.
2. TO RELEASE, WAIVE, HOLD HARMLESS, DISCHARGE, AND COVENANT NOT TO SUE the Releasees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by me (or my child), or to any property belonging to me (or my child), while participating in Bike MS including, but not limited to, any claim that the act or omission complained of was in whole or in part by the negligence or carelessness of the Releasees.

Acknowledgment and Compliance with Rules
I agree to observe all rules and safety procedures that accompany Bike MS and to abide by any decision of an event official relative to my (or my child's) ability to safely participate in the event. I agree to exhibit appropriate behavior at all times and to obey all laws, including all applicable state and local laws and regulations governing cyclists. NMSS and event officials may dismiss me (or my child), without refund, should my (or my child's) behavior endanger the safety of or negatively affect an event, person, facility, or property of any kind.

Severability
I agree that if any portion of this Release is deemed to be invalid, the remainder of the Release will still be binding and enforceable.

Photography Release
I hereby grant full permission to NMSS to use, reuse, reproduce, publish, or republish any photographs, motion pictures, recordings, or any other record of my participation in this event, in any medium now known or hereafter developed, alone or in conjunction with other material, without restriction as to changes or alterations, as well as to use my name, voice, likeness, and/or other indicia of identity, for editorial, educational, promotional, advertising, and commercial purposes, including without limitation in connection with the solicitation of contributions and the furtherance of the corporate objectives of NMSS. Further, I relinquish all rights, title, and interest in any and all photographs, motion pictures, recordings, or other records of Bike MS I may take or capture to NMSS.

I acknowledge and represent that I have carefully read and understand all terms of this Release and Waiver of Liability.

Full Name: __________________________________________________ 
Signature: ___________________________________________________		Date: ______________________
SUPPORT THE RIDE & ADVERTISE
Have your company, club or even your call sign proudly displayed on the back of the
Bike MS: City to Shore EVENT T-Shirt!

If you would like your company logo, club logo, or your call sign in the Super Booster Box this form must be filled out and returned BY August 1st.

Communicator T-shirts are free to all of our volunteers, but sponsor support enables us to pay for them. Please assist us in this effort by asking your employer to make a contribution and, in turn, see their logo on nearly 500 communicator event T-shirts. The same can be done for your local radio club, repeater group etc. You may also show your personal support by having your call sign and others listed in the prestigious communicator Super Booster Box on the back of our communicator Tee shirts.

1)	To have your call sign, appropriate information below
2)	Please make checks payable to ‘National MS Society’
3)	Mail this form and check payable to the ‘National MS Society’ to (BY August 1st):		
MS EVENT COMMUNICATIONS
C/O KATHY STAFFORD (AB2LF)          
128 STONEHAM DRIVE
GLASSBORO, NJ  08028   
4)	If applicable, email lauren.dietz@nmss.org your high resolution company or club logo w/ form BY August 1st 

Please print clearly 

First Name: __________________ Last Name: __________________ 

Call Sign: ____________	Contact Phone Number: (_____) _____ - _________

Call Sign to be listed: _________________________________________________________

Name of Company Logo to be listed: ______________________________________________

Name of Club Logo to be listed: __________________________________________________

Company Logos				$150.00 per logo 	x___(qty.) = $______
Club Logos					$50.00 per logo 	x___(qty.) = $______
Individual Call Signs				$20.00 per call sign 	x___(qty.) = $______

Form and payment due BY August 1				      GRAND TOTAL:   $______