Request edit access
Captain Application
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.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Address *
City *
Province *
Postal Code *
Email *
Phone Number *
Birthdate *
MM
/
DD
/
YYYY
Parent/Guardian Name *
Parent/Guardian Emergency Contact Number *
Participation Related Questions
Please indicate the events you would be interested in participating as a captain. *
Required
Shirt Size *
Can you sit safely and comfortably in a stroller for an extended period of time (1-5 hours) *
Do you require the use of a wheelchair? *
Do you require the use of an assistive device such as a cane, crutches or walker? *
Emergency services agreement: I the Captain, parent or guardian agree that emergency services may be called in an emergency *
Medication Administration Policy: I understand that no member of myTEAM TRIUMPH staff or volunteers can administer any medication *
Medical History Questionaire
Help us better understand your disability by briefly answering the following questions.
Height *
necessary for equipment restrictions
Weight *
necessary for equipment restrictions
Primary diagnosis of your disability *
How long have you had your disability
Please provide any history of seizures
How often. How long do they typically last. Any special requests to help you through a seizure.
Are you continent? And if not, do you require any special accommodations?
Would you require any special feeding or hydration during the event? If yes, please indicate
How would you plan to stay hydrated and nourished during the event?
How often you would need to drink or eat. Do you need help with eating and drinking.
Please indicate any other medical or physical concerns that we should be aware of?
Other pertinent information about your disability?
Waiver
By signing I acknowledge my understanding 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 potentially may be 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. *
Photo Release *
I grant to myTEAM TRIUMPH: Wings of Texas, its representatives and assigns the right to take photographs of me and my property in connection with my participation in said organization’s events. I authorize myTEAM TRIUMPH: Wings of Texas, its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I agree that myTEAM TRIUMPH: Wings of Texas may use such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy