2015 Crew Assignment FormPlease fill in all of the information below and return the form by fax, post or email.

1. Contact Information: (Please PRINT Clearly)

Name: __________________________________________________Date of Birth_________________________

Home Phone: __________________________________ Work Phone: __________________________________

Email: ________________________________________ Cell Number: __________________________________

2. Valid Licenses/Certifications (please fax a copy with your assignment form to 604-684-9296):

o MD o RN/LVN/LPN o Athletic Trainer o Special License (C 3, etc) _____________________o OT/PT o Chiropractor o Podiatrist o Acupuncture/Hollistic Medicine _________________o RMT o Paramedic o ASL Interpreter o Other _____________________________________

3. Weight you are capable of lifting:

o 0 lbs o 10-20 lbs o 20-30 lbs o 30-40 lbs o 40+ lbs

4. Vehicles you are comfortable driving:

o None o Van (7 person minivan)or SUV

o 15 ft. Truck o 24 ft. Truck o Manual Transmission Truck

5. Assignment Choices: We will do our best to accommodate your choices, but the needs of the event come first.

1. ________________________________2. ________________________________3. ________________________________

4. ________________________________

6. Can you provide your own vehicle? o Yes o No *If yes, what make of vehicle are you bringing ____________________________________

*Please note that certain teams are encouraged to provide their personal vehicle for transportation. Fuel Reimbursements will be issued onsite.

7. Are you interested in being a Crew Captain? o Yes o No

8. Are you currently a student? o Yes o No

9 Are you looking to collect volunteer hours/references? o Yes o No

10. Are you part of a corporate team? o Yes o No

12. Would you be interested in hosting a Crew info session? o Yes o No

13. Are you available on the Friday (Day before event weekend) o Yes o No

14. Are you a returning Crew Member? o Yes o NoIf “Yes”, which Team were you assigned to last year? ___________________________________

15. If you have an existing Crew Member you would like to be with for the event weekend, please indicate the Crew Members name: _______________________________________________________________________

_______________________________________________________________________

16. If you have a friend or family member who is interested, write down their name and email. We would be happy to send them some information about Crew.

_________________________________________________________________________

17. Special Considerations: Please list any physical limitations, injuries, allergies, refer a friend etc.

_________________________________________________________________________

_________________________________________________________________________

18. Registration Fee

Please submit your non-refundable $25 registration fee with this form. If you are submitting a personal cheque please make it payable to: Ride to Conquer Cancer

● Visa ● Mastercard ● Amex

Cardholder Name Card Number Expiry / Signature

Thank you for supporting the Ride to Conquer Cancer!

Return to: The Ride to Conquer Cancer303 – 698 Seymour Street Or Via Email: ecunnington@conquercancer.caVancouver, BC V6B 3K6 Or Via Fax: (604) 684-9296Attn.: Emma Cunnington – Volunteer & Crew Coordinator