Annual Jack Daniel’s Operation Ride Home

Service Member Participation Application

Service Member Information

Name of Service Member: ________________________________________

Grade: ____________________________ (E-1, E-2, E-3, E-4, E-5)

Service Branch: ☐Army ☐Marine Corps ☐Navy ☐Air Force ☐Coast Guard

Military Installation: __________________________ Is the Service Member Deployed: ☐Yes ☐No

Command/Unit: ______________________ Command Senior NCO: _______________________

ASYMCA Branch: ____________________________

Primary Contact for Application (if different from Service Member): ___________________________

Relationship to Service Member: _________________________

Phone Number (Primary Contact for Application):_________________________	☐Home	☐Mobile

Secondary Phone Number (Primary Contact for Application):________________☐Home	☐Mobile

Email Address (Primary Contact for Application): ________________________________________

Number of Adult Travelers (including service member): _______________

Number of Children Travelers (ages 2-18): __________________

Number of Infant Travelers (under age 2; on lap if flying) ______________

ASYMCA Branch calculate mileage: Flying or Driving: ☐Flying ☐Driving

Travel Origin (City, State, ZIP): _____________________________

Travel Destination (City, State, ZIP): ________________________

Please tell us why you need help getting home (Up to 250 Words)

(If additional space is needed, please add an additional piece of paper)

Approving Command Point of Contact

Date Approved: __________ COMMAND PRIORITY #:_______

Name: ________________________________________________________________________________________

Title: _________________________________________________________________________________________

Duty Station: ___________________________________________________________________________________

Contact Telephone Number: _______________________________________________________________________

Contact Email: __________________________________________________________________________________

Signature: _____________________________________________________________________________________

Verified Leave Dates for Service Member: ____________________________________________________________

☐From time to time, the Armed Services YMCA and Jack Daniel’s likes to highlight those benefiting from Operation Ride Home through pictures on websites and social media (e.g. Facebook, Instagram, Twitter, etc.) and media outreach. Media may include but will not be limited to television or print interviews at a local or national perspective. The above listed service member and/or family is approved for involvement if selected. By checking the box, you agree to the terms.

For ASYMCA Internal Use
Date Received ________________
Amount of Assistance: _$________
☐Approved ☐Waitlist

(Complete the balance of the Application Form once the selected and travel is approved by the command.)

Releases

Liability Release*

☐ I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event and program. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to the activities of Armed Services YMCA programming for myself and my family members. I will not hold the Armed Services YMCA, Jack Daniel’s, and Brown-Forman Corporation (Brown-Forman) liable for any injuries, accident or death incurred during participation in this event and programming or in transit to and from the program or event for any reason, whether caused by equipment or the act or omissions of others. I will not hold the Armed Services YMCA, Jack Daniel’s and Brown-Forman liable for missed flights, cancelled flights, changed flights, delayed flights or additional financial costs or obligations incurred for any reason before, during or after participation in this event and program.

I forever discharge and hold harmless and covenant not to sue the Armed Services YMCA of the USA, ASYMCA of ____________________ (insert branch name), Jack Daniel’s and Brown-Forman, and all their officers and personnel, employees, representatives, and their successors or assigns. I also waive all claims, demands, damages, actions, or suits of any nature or legal basis against the Armed Services YMCA’s, Jack Daniel’s, and Brown-Forman’s officers, employees, personnel, and their successors or assigns arising from any accident, injury or alleged injury, including death, and property damage or loss that occurs incident to my entering upon and engaging in any activities that are associated with this program and event.

I also understand that if I have, or am the custodian of a minor child, and choose to allow them to attend and/or participate in the program and event, that the same risks and considerations detailed above also apply to them. I understand that no special measures have been taken to specifically address the needs, tendencies and care of the minor children. Therefore, I fully appreciate the special risks to the minor children in my custody, and understand that I am solely responsible for their actions and care.

I understand that this waiver is legally binding on me and my heirs, executors and administrators. I also acknowledge that I am aware of the risks involved in my and my minor children’s participation in this event. I understand that I may be removed from participating in this program and event if I do not follow the rules of this event. I further acknowledge that I have carefully read this release, understand the contents thereof, and sign this release as my free and voluntary act.

By checking the box, you agree to the terms.

Photo & Media Release*

☐ I hereby grant the non-profit Armed Services YMCA and its partner Jack Daniel’s permission to use the photographic/video images taken of myself and/or my dependents and minor children and that the ASYMCA shall have all rights, title and interests to the image(s) and the copyrights thereto and all the related rights for their entire terms, including renewal, free and clear of all encumbrances.

By checking the box, you agree to the terms.

Operation Ride Home Family Photo and Video Requirement*

☐ If selected, I agree to upload a photo of me and/or my dependents and minor children with my family taken during the holiday visit. The photo may be uploaded to the Armed Services YMCA Facebook page or emailed to my ASYMCA Branch POC and OpRideHome@asymca.org no later than January 15, 2018. By checking the box, you agree to the terms.

☐ If selected, I will consider sharing a 10-second or more video of our sponsored holiday visit. The video may be uploaded to the Armed Services YMCA Facebook page or emailed to my ASYMCA Branch POC and OpRideHome@asymca.org no later than January 15, 2018. Get creative with testimonials, surprise videos, and Vine videos!

By checking the box, you agree to the terms.

Armed Services YMCA Media Option

☐ Yes, my family and I would be available during our holiday trip for any TV or print interviews associated with Operation Ride Home. The ASYMCA will participate in national media events in NYC, LA, San Diego and other markets. By checking the box, you agree to the terms.

Signature: _______________________________ Date: ______________________

Names and Ages of Each Family Member Traveling

Service Member (Exactly as printed on ID) ____________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Spouse/If Applicable (Exactly as printed on ID) _________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Telephone Number: ___________________________ ☐Home	☐Mobile

Secondary Telephone Number: __________________ ☐Home	☐Mobile

Email address: _________________________________________________

Name of Dependent Child: ________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: ________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

Name of Dependent Child: _________________________________________

Date of Birth (Required for booking air travel): ___/___/___ (mm/dd/yyyy) Age: ____ Gender ☐ M ☐ F

*If additional space is needed, for listing dependent children travelling with a service member, please collect the same data listed above and provide on an additional sheet of paper.

Please send a thank you to the Operation Ride Home Sponsor: Brown-Forman & Jack Daniel’s