Application Form for Sears National Kids Cancer Ride

Welcome to the Sears National Kids Cancer Ride National Application Form. Please complete this form if you are interested in participating as a National Rider for the Sears National Kids Cancer Ride in 2010. Along with this Application Form, you may be asked to participate in a phone or face to face meeting with one of the Event Organizers. Successful applicants will also be asked to submit a recent medical certificate, and a commitment to minimum levels of fundraising. You will also be asked to sign an agreement with the Event agreeing to a program of training and nutrition as well as a Release of Liability Waiver. Only one submission per applicant. Good luck! We hope to see you on the 2010 Sears National Kids Cancer Ride.

1. Please provide us with the following information:

Name (first, middle, last) *This question is required

Address (number, street, apartment) *This question is required

City *This question is required

Province *This question is required

Postal Code *This question is required

Email Address *This question is required

Home Phone Number (including area code) *This question is required

Mobile Phone (including area code) *This question is required

Gender (male or female) *This question is required

Height *This question is required

Weight *This question is required

Date of birth (dd/mm/yyyy) *This question is required

2. List and provide details of any medical conditions that may impact your training prior or during the event? *This question is required

3. List medications that you are currently taking (include supplements, homeopathic and/or naturopathic remedies, etc.) *This question is required

4. Do you have any allergies *This question is required

No
Yes (if yes, please indicate which ones) Please enter an 'other' value for this selection.

5. Have you ever smoked cigarettes? *This question is required

No
Yes (if yes, indicate if or when you stopped) Please enter an 'other' value for this selection.

6. How many alcoholic beverages do you consume in an average week? *This question is required

7. What athletics do you currently participate in (include both competitive and recreational sports)? *This question is required

8. Describe the most adventurous athletic event you have participated in, and what prompted your involvement? *This question is required

9. How many times per week do you engage in aerobic activity for periods of longer than 60 minutes? *This question is required

10. Choose the answer that best describes your current level of fitness? *This question is required

I'm not fit but committed to getting fit
I am moderately fit and engage in aerobic activity 3X per week
I am very fit and compete in master level or higher sporting events
I do not participate in competitive sports but I enjoy physical activity
Other, please specify Please enter an 'other' value for this selection.

11. Please describe why you want to be one of the National Riders on the Sears National Kids Cancer Ride? *This question is required

12. Please describe why you think you are a good candidate for the Sears National Kids Cancer Ride? *This question is required

13. Have you (or someone close to you) ever been impacted by cancer? *This question is required

No
Yes (if yes, explain how) Please enter an 'other' value for this selection.

14. On a scale from 1-5, please rate the following items: *This question is required

	Very Low	Low	Neutral	High	Very High
Confidence you will have sufficient training time for this event?
Commitment to following the training and nutritional plan?

15. Are you confident that with the appropriate training and nutritional plan, you will be able to complete the Sears National Kids Cancer Ride? *This question is required

Yes (please clarify) Please enter an 'other' value for this selection.
No (please clarify) Please enter an 'other' value for this selection.

16. Please indicate how you heard about the Sears National Kids Cancer Ride? *This question is required

From a relative, friend or colleague
Radio or Television
Newspaper or magazine
Flyer or brochure
Sears Store
Other, please specify Please enter an 'other' value for this selection.

17. Please provide three references that support your participation in the Sears National Kids Cancer Ride? *This question is required

Name 1 (first, last) Please enter an 'other' value for this selection.
Contact phone Number 1 (including area code) Please enter an 'other' value for this selection.
Name 2 (first, last) Please enter an 'other' value for this selection.
Contact phone Number 2 (including area code) Please enter an 'other' value for this selection.
Name 3 (first, last) Please enter an 'other' value for this selection.
Contact phone Number 3 (including area code) Please enter an 'other' value for this selection.

18. Please outline previous charity and non-charity events you have participated in? *This question is required

19. How do you envision your role/participation in helping the Sears National Kids Cancer Ride with securing sponsors, fundraising and enlisting volunteers from within your community or beyond?

20. Any other comments or thoughts?