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Captain Application - 2019
Thank you for your interest in becoming an Captain! We want you to have the best & safest experience possible. As such, we are requesting the following information. To apply, please complete and submit the form below.
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Last Name *
First Name *
Address *
City *
State *
Zip *
Email *
Phone *
xxx-xxx-xxxx
Birthdate *
mm/dd/yyyy
MM
/
DD
/
YYYY
Gender *
Parent/Guardian Name *
Emergency Contact Phone *
xxx-xxx-xxxx    Phone # of Parent/Guardian/other
Shirt Size *
Participation Related Questions
Event *
Please indicate the events you would be interested in participating as a captain.
Required
Region *
What Region are you nearest to, or what region are you most likely to participate in?
Wheelchair & Assistive Devices.  
Wheelchair? *
Do you require a wheelchair?
Sit Time? *
 Can you sit safely and comfortably in a stroller or wheelchair for an extended period of time (1-5 hours).
Alternative Devices? *
Do you require the use of an assistive device such as a cane, walker, or crutches?
Medical History Questionaire
Help us better understand your disability by briefly responding to the following:
Medication Administration Policy: *
I understand that no member of myTEAM TRIUMPH staff or volunteers can administer any medication
Height *
Necessary for equipment restrictions
Weight *
Necessary for equipment restrictions
Primary diagnosis of disability *
Duration of Disability *
How long have you had this disability?
Seizures *
Please provide any history of seizures. Have you experienced a seizure? How often. How long do they typically last. Any special requests to help you through a seizure.
Continence *
Are you continent? And if not, do you require any special accommodations?
Hydration and Nourishment *
How would you plan to stay hydrated and nourished during the event? How often, and do you need assistance with eating and drinking?
Other Accommodations
Please indicate any other medical or physical concerns that we should be aware of?
Other Disability Information?
Waiver Agreement *
By signing this waiver agreement, I acknowledge that my participation in any myTEAM TRIUMPH, Inc. event and/or any pre- or post-event activities, including any training sessions or other preparatory activity (collectively, the “Event”), involves rigorous physical activity and that it may be potentially hazardous. I attest and verify that my ability to participate in the Event has been verified by a licensed medical doctor. I expressly assume all known and unknown risks associated with the Event, including but not limited to: loss of or damage to my property; injury (including death); accidents; the effects of weather; and terrain conditions that may vary widely, and that may include uneven and/or slippery surfaces, spectators, participants, and natural and manmade obstacles (including without limitation, vehicles, security barriers, signs, cables, mats, and debris on the course). In consideration of my participation in the Event, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns, waive any and all rights, claims and causes of action I have or may have against any Race Organizer that may arise as a result of my participation in the Event. For these purposes, a “Race Organizer” is any one or more of the following: myTEAM TRIUMPH, Inc. and their affiliates including the individual(s) who will assist me in the Event (Angels, Volunteers and others); all governmental agencies representing the territory in which the Event will be held; all sponsors, agents, vendors, and contractors of or for the Event; medical service providers; and the officers, directors, employees, representatives, successors and assigns of each of the foregoing. I hereby agree to indemnify all Race Organizers for all claims and losses (including attorney’s fees and court costs), which may be brought against any one or more of them by anyone claiming to have been injured or otherwise to have suffered loss or damage as a result of my participation in the Event. I further grant full permission to any and all of the foregoing to store, use and/or reproduce my image or likeness by any audio and/or visual recording technique (including electronic/digital) now in existence or hereafter invented, for any legitimate purpose, including commercial sales and marketing purposes. I understand and agree that information about me that is collected by myTEAM TRIUMPH, Inc. or the Race Organizers, including without limitation information on this form and my Event results may be disclosed to third parties for any legitimate purpose, including commercial sales and marketing purposes, and that it may be subject to re-disclosure by the recipient(s). I acknowledge and agree to abide by any Official Rules for the Event that may be posted at the Event or on the Event’s website. I hereby represent and warrant that I am 18 years of age or older or, if applicable, that I am the parent or legal guardian of the child under the age of 18 years old who I am registering for the Event and that I have the full power and authority to agree to these terms on behalf of such child, and to bind him/her to these terms.
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