2012 Blue Valor Run Application

Applications Due By No Later Than March 01, 2012

If you would like to register for the Blue Valor Run, please complete the following application by no later than March 1, 2012. Each application requires a $25 non-refundable registration fee. Registration is limited and is available on a first-come, first-served basis.

If you have any questions, please contact the P.O. Ken Tietjen Memorial Foundation at (732) 887-0645. Thank you for your participation!

9/11 Blue Valor Run Registration Form

Personal Information

^* First Name

Middle In

^* Last Name

^* Address

^* City

^* State

^* Zip Code

^* Phone Number

Alternate Phone

^* Email Address

^*Sex Male
Female

^* Shirt Size Small
Medium
Large
Extra Large
2XL
Other (Please specify)

I am a Police Officer (active)
Police Officer (retired)
Surviving family member or friend of officer killed in the line of duty
Surviving family member or friend of a civilian killed on 9/11
Federal Officer
Court Officer
Corrections Officer
Civilian
Other (Please specify)

How did you hear about this ride?

Would you like to ride in remembrance of a particular law enforcement officer who died in the line of duty? If yes, please print that officer's name and department:

What is your relationship to this officer?

Affiliation Information

I am affiliated with a law enforcement agency

If you are affiliated with a law enforcement agency, please complete this section.

^* Department Name

^* Address

^* City

^* State

^* Zip Code

^*Telephone Number

Alternate Phone

Driver Information

Make and model of your motorcycle

^* Driver's license number

^* State

^* Expiration Date

^* Name of insurance company

^* Policy number

^* Do you have a motorcycle endorsement? Yes
No

Passenger Information

I will have a passenger

If you plan to carry a passenger on your bike, please complete this section. Please note that all passengers must be 21 years of age or older.

^* First Name

Middle In

^* Last Name

^* Address

^* City

^* State

^* Zip Code

^* Phone Number

Alternate Phone

^* Email Address

^*Sex Male
Female

^* Shirt Size Small
Medium
Large
Extra Large
2XL

Medical Information

^* Name of insurance carrier

^* Group number

^* ID number

^* Date of Birth

Blood type

Do you have any allergies or medical conditions that may affect your ability to participate in/complete the ride?

Emergency Contact Information 1

^* Name

^* Relationship

^* Address

^* Phone number

Alternate number

Emergency Contact Information 2

Name

Relationship

Address

Phone number

Alternate number

Create An Account

Choose a password for your account. You will need to use your email address and this password to manually enter any donations you receive.

^* Password

Choose Your Membership Type

You can change your Membership Type, as well as set your own custom goal, at any time after you register.

Membership Type Gold (Goal: $1,200.00)
Silver (Goal: $911.00)

Hold Harmless Agreement

I, the undersigned, understand that the described activities above and herein called the 9/11 Blue Valor Run ("The Ride") refers to the actual event and ride and those individuals and groups organizing, sponsoring, volunteering, or otherwise connected with the production or management of this event.
The Ride involves motorcycle activities, which can be hazardous. There are many dangers and risks associated with motorcycles including, but not limited to, injury or death resulting from collision with pedestrians, vehicles or other fixed or moving objects; dangers arising from surface hazards such as potholes or poor road conditions; equipment failure, inadequate safety equipment, conditions stemming from weather, the negligence of myself and/or others, and trauma or injury arising from the stresses caused by physical exertion.
I understand that The Ride activity is conducted over public roads upon which hazards of traveling are to be expected. I acknowledge that The Ride has no responsibility for the condition or maintenance of the roads or facilities upon which The Ride event will be conducted. I agree to accept full responsibility for the condition of my motorcycle and I take full responsibility to wear a DOT-approved helmet throughout the ride and in accordance with all local laws.
I certify that I have adequate liability insurance for myself and any passengers as required by current motor vehicle operation laws and I agree that I will not carry any passengers under the age of 21 throughout the duration of The Ride.
I agree, as a consideration of, and in consideration for, being allowed to participate in The Ride event, to freely and expressly assume all risks if injury or death to me, or property loss or damage, including injury, death, loss or damage attributable to the negligence of The Ride and the spouses, promoters or affiliated organizations (including The Twin Towers Initiative and the National Law Enforcement Officers Memorial Fund), and their respective agents, directors, officers, volunteers and employees (the "Released Parties").
I also agree to release and forever discharge the Released Parties from any and all responsibility or liability for any and all injuries, damages or theft of my property that result, either directly or otherwise, from my participation in or attendance at The Ride event. I further agree to indemnify and hold harmless the Released Parties for all expenses incurred due to my participation in The Ride, including medical and legal or other expenses. As liquidated damages, I hereby agree that if any Released Parties are forced to defend any action, lawsuit or litigation by me, my executors, or my heirs on my behalf, I agree to pay the Released Parties' costs and attorney fees if they successfully defend such action, lawsuit or litigation.
If I am injured or become ill during The Ride, I give permission for transportation to any medical facility and/or hospital and I consent to and authorize the provision of emergency first aid or medical treatment. I agree to be solely responsibly for any costs related to such first aid or treatment.
I further agree to allow all photographs, video and/or images reproduced in association with The Ride event to be used in any way by The Ride, and release all claim to rights in and to those images, without restriction.
I am aware that this is a release of liability and a contract between myself and The Ride. I am signing it freely and of my own accord and I recognize and agree that it is binding upon myself, my heirs, my assigns, and in the event that I am signing on behalf of minors, I have full legal authority to do so, and I realize the binding effect on them, as well as myself. In this Release, the use of the word "I", "me", and "my" shall be deemed to include my spouse or partner and any minor on whose behalf I am signing it. Should a court of competent jurisdiction declare any word, sentence, clause, paragraph, or part of this agreement unenforceable, the remaining parts shall remain in full force and effect. A copy of this Release can be used as if it were an original.

I, THE UNDERSIGNED, HAVE CAREFULLY READ THIS ASSUMPTION OF RISK, RELEASE OF LIABILITY, COVENANT NOT TO SUE, AND INDEMNITY AGREEMENT ("Release"). I FULLY UNDERSTAND AND AGREE TO ITS CONTENTS. FURTHER, I REPRESENT THAT ALL INFORMATION ON THIS REGISTRATION FORM IS TRUE AND ACCURATE AND ASSUME FULL LIABILITY FOR ANY ERRORS OR OMMISSIONS.