2015 Crew Assignment Form

Please 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

1.  Are you currently a student? ◊Yes ◊No

2.  Are you looking to collect volunteer hours/references? ◊ Yes ◊No

3.  Please indicate your t-shirt size S/M/L/XL

4.  Do you require a vegetarian Meal ◊Yes ◊No

Please select which cancer fund your fundraising dollars will go to. (If there is no selection made, it will go to Partners in Discovery Cancer Priority Projects.)ex. Lung, Breast, rare cancers, prostate, head and neck etc.

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.

______

______

Thank you for supporting the Ride to Conquer Cancer!

Return to: The Ride to Conquer Cancer

303 – 698 Seymour Street Or Via Email:
Vancouver, BC V6B 3K6 Or Via Fax: (604) 684-9296

Attn.: Emma Cunnington – Volunteer & Crew Coordinator