Volunteer Registration Form
Monday – Friday, June 11-15, 2012
Westminster Presbyterian Church
3900 West End Ave., Nashville TN 37205
Thank you for your interest in volunteering for the Lose the Training Wheels™ bike camp
presented by Down Syndrome Association of Middle Tennessee. We are pleased to be
partnering with the Pujols Family Foundation to bring this program to our community for
the third time, and would like to thank you in advance for your contribution.
Please complete this form in its entirety and return form to erin@dsamt.org or
fax to 615.386.9754. You can also send forms by mail to: DSAMT, 111 North Wilson
Boulevard, Nashville, TN 37205
If you have any questions please contact Erin Kice at 615-386-9002 or email
erin_dsamt@bellsouth.net
Volunteer Personal Information
Volunteer First Name: __________________________ Last Name: _________________________
T-shirt Size: (circle) XS S M L XL 2XL
Birth date: ____________________________
Parent/Guardian name (if under 18 yrs.): _____________________________________________
Home Phone: (
)
Cell: (
)
Office: (
)__________
E-mail Address: _____________________________________________________________________
Preferred Contact Method: (circle) home phone cell email
Street: _______________________________________________________________________
City: ____________________________________________ State: ____ Zip: ____________
Emergency Contact Information
In the event of an emergency, who should we contact?
Name: _______________________________________
Phone Number: (
)
Relationship: _______________________
Alt. Phone No: (
)
Volunteer Role
Volunteer Spotter – as a volunteer spotter you will walk or run alongside a child as they
are learning to ride a bike. Spotters provide physical support and
encouragement to the participants as they master the skill of riding a bike.
Spotters are supervised and trained by Lose the Training Wheels staff.
Please determine your highest level of fitness:
I can jog at a moderate pace for one hour with short breaks
I can walk fast for one hour with short breaks
I can walk steadily for one hour with short breaks
I cannot walk at a steady pace for one hour with short breaks
Your Commitment
Please indicate the times when you will be available to volunteer. Please note that we
recommend that volunteers attend all five days of camp for the same session. Campers
bond with their volunteers and rely on the same person to be there each day to help
them learn to ride. It is important that you arrive 15 minutes prior to your session start
time for a daily briefing. It is also highly recommended that volunteers attend the short
Volunteer Training Session on Sunday prior to camp week. The training should last about
30 minutes.
I can work all 5 days of camp
during my selected session(s)!
I’m available for these sessions:
8:30am-9:45am
I can’t work all week, but am
available on the following days during
my selected session(s)
10:05am – 11:20am
11:40 pm – 12:55 pm
Monday, June 11
Tuesday, June 12
Wednesday, June 13
Thursday, June 14
Friday, June 15
1:55pm – 3:10pm
3:30pm-4:45pm
Volunteer training Sunday
afternoon prior to start of camp
Personal Information
What is your profession? _____________________________________________________________
Do you have experience working with individuals with disabilities? Yes
No
If yes, please explain: _______________________________________________________________
_____________________________________________________________________________________
What is your reason for volunteering with Lose The Training Wheels™?
Are you interested in volunteering with DSAMT for other activities in the future?
If yes, in what types of activities are you interested in participating?
O
Annual Nashville Buddy Walk – October 20, 2012 at Centennial Park
O
Summer Family Picnic
O
Other Summer Camps
O
Circle of Friends social activities
O
Skilled Volunteer Help (i.e. computer work, website help, etc.)
Please describe the skills you would like to put to use:
___________________________________________________
___________________________________________________
___________________________________________________
Volunteer Release Form
Program: Lose the Training Wheels™
Description: A weeklong bike program that uses adapted equipment to help individuals
with disabilities learn to ride a two-wheel bicycle.
I give permission for my child/myself (print name below)
To be photographed and/or videotaped by a Down Syndrome Association of Middle
Tennessee or Pujols Family Foundation representative or media for use in publicizing the
above mentioned program in print or electronic media. I acknowledge and agree that
my participation in photographs and videos may be edited and used in whole or in
part as desired for this program, which may be produced, duplicated, distributed and
used for informational purposes. I understand that photographs and video become the
property of your organization without compensation to me. I understand and authorize
the use in writing or otherwise the name or identity of the above participant.
By signing, I hereby expressly acknowledge that volunteering at a Lose The Training
Wheels™ bike program, like many activities such as swimming, golf, soccer, and
gymnastics; involves movement and physical activity, and that injury or mishap are
possibilities in spite of all reasonable safeguards and precautions taken. I accept such
risks as reasonable and proper, and agree to hold harmless the principals & staff of
Down Syndrome Association of Middle Tennessee, Pujols Family Foundation, and Lose
the Training Wheels, Inc.
_______________________________________________________
Signature
Print Name ______________________________________
Date: _____________
______________________________________________________________
Parent or Guardian Signature (if participant is under 18)
Print Name ______________________________________
Date: _____________
Relationship (for guardian) _____________________________________