1. Personal Information |
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Badge Name:
(Exactly how you would like it printed on your name tag) |
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Address:
Home Business |
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| Day Phone: (including area code) |
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| Evening Phone: (including area code) |
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| Fax: (including area code) |
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| E-mail: |
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Sex: Male Female
Birth date:
T-Shirt Size: Adult Child |
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2. Emergency Contact Information |
| Name of person to contact: (Not Traveling with You) |
| Relationship: |
| Emergency Contact Phone: |
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3. General Waiver Printer Friendly Version:  |
I, the undersigned, certify I am 18 years of age or older and that I am entering into this Agreement on behalf of myself or as the Parent of a participant or as authorized Legal Guardian for another minor that is under 18 years of age ("Ward") identified above.
In consideration of my or my child or Ward's participation in the NKF 2008 U.S. Transplant Games (the "Event") presented by National Kidney Foundation and sponsored by Novartis Pharmaceuticals, I agree on my behalf or on behalf of my child or Ward to assume the risks incidental to such participation (which risks may include, among other things, physical injury related or unrelated to their present health condition and/or related to all travel, lodging and non-participatory activities incidental to such Event) and, on my own behalf or on behalf of my child or Ward, and on behalf of my or my child or Ward's heirs, executors and administrators, release and forever discharge the released parties defined below, of and from all liabilities, claims, actions, damages, costs or expenses of any nature arising out of or in any way connected with my or my child or Ward's participation in such activity, and further agree to indemnify and hold each of the released parties harmless against any and all such liabilities, claims, actions, damages, costs or expenses, including, but not limited to, all attorney's fees and disbursements. For this Event, the released parties are the National Kidney Foundation, David L. Lawrence Convention Center, University of Pittsburgh, all Event sponsors, volunteers, officials, venues, and providers, their parent, related and affiliated companies, and the officers, directors, employees, agents, representatives, successors and assigns of each of the foregoing entities. I UNDERSTAND THAT THIS RELEASE AND INDEMNITY AGREEMENT INCLUDES ANY CLAIMS BASED ON THE NEGLIGENCE, ACTION OR INACTION OF ANY OF THE ABOVE RELEASED PARTIES AND COVERS BODILY INJURY (INCLUDING DEATH) AND PROPERTY LOSS OR DAMAGE, WHETHER SUFFERED BY ME OR MY CHILD OR WARD, BEFORE, DURING OR AFTER SUCH PARTICIPATION. I declare that I or my child or Ward am or is physically fit and have or has the skill level required to participate in this particular event and have based this representation on a physician's medical advice or my decision to knowingly proceed in the absence of such advice. I further authorize medical treatment for myself or my child or Ward, at my cost, if the need arises. If I or my child or Ward is an athlete, I understand and agree that my physician or his agent may provide personal health information (PHI) to the organizers of the NKF U.S. Transplant Games. I understand that this information will be kept confidential and will only be used to determine my or their eligibility to participate in the Games and to provide medical assistance to me or my child or Ward if necessary, and will not be shared with any person or organization except for the purposes as specified above. I understand that the name and logo(s) of the NKF U.S. Transplant Games are trademarks and the intellectual property of the National Kidney Foundation, Inc. and that any unauthorized use of the NKF U.S. Transplant Games name and logo(s) without written consent of the National Kidney Foundation, Inc. is prohibited and may be subject to civil and criminal penalties under the laws of the United States. I further understand that I agree not to otherwise grant commercial advertising rights connected with my or my child or Ward's participation in the Games. I further grant the National Kidney Foundation and all Event sponsors, their parents, related and affiliated companies, the right to photograph and/or videotape me or my child or Ward and further to use my or my child or Ward's name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising and promotional materials without reservation or limitation, although I understand that there is no obligation to exercise said rights herein granted. This Agreement shall be governed by the laws of the State of Pennsylvania, and any legal action relating to or arising out of this Agreement shall be commenced exclusively in the United States District Court for the Western District of Pennsylvania or the state courts of Pennsylvania in and for the Third (Allegheny County, Pennsylvania) Judicial District. I have fully read and understand and agree to the above terms: |
Digital Signature of Registrant (or Parent or Legal Guardian of Ward)
By checking this box, I am digitally signing that I have read and will abide by the above waiver. |
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4. Profession & Specialty (please check all that apply) |
Profession:
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Specialty:
Do you have professional liability insurance? Yes No
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| If yes, and you are a staff member at UPMC or University of Pittsburgh, please skip to the next section. |
If yes, and you are a private practitioner, please submit a certificate of insurance to:
DAVID TUMBAS
UPMC SPORTS MEDICINE
3200 SOUTH WATER STREET
PITTSBURGH, PA 15203
Your insurance carrier/risk manager must verify on the certificate that your participation at this event is covered. |
| If yes, and you work at an institution or health care facility other than UPMC or University of Pittsburgh, list the name and telephone number of the risk manager at your facility. |
Name of Risk Manager at your facility:
Phone Number:
(Proof of certification and/or licensure will also be required)
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5. Availability (please check all that apply) |
Please specify your availability on the dates indicated below:
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6. Areas of Interest |
Please prioritize your area of interest and location (1=1st choice, 2=2nd choice, etc.):
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7. Qualifications/Special Considerations |
Please list any special qualifications or volunteer experience, talents, skills you possess which may be helpful to determine which best fits your capabilities and interests.
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| Do you have any special considerations and/or restrictions that may be related to your volunteer service (i.e.: no standing, no heavy lifting, etc.)? Yes No
Please list them here:
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8. Survey (Optional) |
To help us learn more about you, please complete the following survey. Any and all of the questions are optional, however your feedback assists us in gathering information to gain more sponsor support for the Games and its participants.
Please check all of the following that best describes you:
Family Member/Friend of a Transplant Games participant
Donor Family Member
Living Donor
Transplant Recipient
Transplant Professional
Resident of Pennsylvania/Surrounding State (No affiliation with NKF and/or U.S. Transplant Games)
Other
Please specify:
Have you already declared that you want to be an organ donor? Yes No
If yes, how? (check all that apply):
Discussed my decision with my family
Indicated my decision on my Driver’s License
Signed a Uniform Donor Card
If no, may we ask why?
Would you be interested in receiving information on organ and tissue donation?
Yes No
How did you hear about volunteering for the NKF U.S. Transplant Games? (check all that apply)
Word of Mouth Direct Mail/Brochure E-mail Newspaper Radio
Other, please specify:
Why are you volunteering?
What is your race/ethnicity?
American Indian and Alaska Native Asian Black or African-American
Hispanic or Latino Native Hawaiian and Other Pacific Islander
White or Caucasian Some other race/ethnicity
Please specify:
What is the highest level of education you have achieved?
Elementary School High School Technical School
Some College-no degree College Degree Masters or Ph.D.
Medical Doctor Other
Please specify:
Which of the following best describes your occupation?
Senior management Other management Professional
Technical Sales Education Homemaker/full-time parent
Student Retired Not employed Other
Please specify:
What is your total household income?
What is your current marital status?
Please indicate the number of people in your household, including yourself: |
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