ROTARY CLUB OF CRANBROOK SUNRISE (DISTRICT 5080)

IRON LUNG / TRAILER

REQUEST PACKAGE

FORMS AND

INSTRUCTIONS


How to Use a Word Document “Fillable Form”

All of the forms in this Iron Lung Request Package are “fillable” Word documents. This form should be completed using Microsoft Word.

For each of the included forms, to fill in the required information, simply place your cursor on / inside / on top of / in the center of the gray boxes that look like the following: CLICK HERE to Enter Information. Once your cursor is in the center of the box, simply CLICK your mouse and start typing. When you do this, the box will immediately disappear and will instead be filled with the text that you are entering. There is no limit to the amount of text that you can enter in these boxes. The page will expand to adapt to the amount of text that you enter. Do NOT place your cursor in front of or behind the box. If you do that, the box will not disappear. You want the box to disappear. For any box that does not apply to your use of the Iron Lung, simply enter “NA” for “not applicable”.


Requesting the Rotary Club of Cranbrook Sunrise (District 5080) Iron Lung and Trailer

Rotary Club of Cranbrook Sunrise (District 5080) has an iron lung and customized trailer (fully equipped with display material) available for use principally by the clubs in District 5080 to help create/increase community awareness and raise funds for Polio Eradication. They are also available for use out of District but only if not previously committed to a District 5080 club or District event. The Rotary Club of Cranbrook Sunrise (District 5080) will always have priority use of the lung. Any conflict on bookings will be resolved by mutually negotiated agreement.

The lung may be scheduled for all of the following events:

·  District Events (these will have priority over club events)

·  Club fundraising events (priority will be given to polio fundraisers)

·  Parades

·  Exhibits at community gatherings

·  Other events where polio eradication will be promoted

·  Club Meetings

·  Out of District Events (i.e.: Pacific Northwest PETS, Zone Institute, etc.)

The following forms are contained in this Request Package

·  Trailer Towing Information / Club Certification Form

·  Application for use of the Rotary Club of Cranbrook Sunrise (District 5080) Iron Lung

·  Iron Lung Usage Report’

The following additional documents must be provided when submitting your request

·  Proof of insurance on the vehicle(s) that will be towing the iron lung

·  Copy of RI Insurance Certificate for your Iron Lung Event

How to request use of the trailer and iron lung

  1. First of all, check the Polio Calendar to see if the trailer is available on the date that you want to reserve it. Check the District 5080 website at www.clubrunner.ca/5080 and consult the site page under Foundation – Polio Plus.
  2. Complete ALL of the paperwork in this package.
  3. Submit the completed paperwork included in this package along with all required supporting documentation to:

PDG Allan Davis – Rotary Club of Cranbrook Sunrise (District 5080) Polio Eradication Chair

Via email at

Or by phone at 250-426-5584

Or by mail at 1446 Hunter Rd., Cranbrook, BC, Canada, V1C 6V6

  1. Once your usage request has been approved, you will be issued a “Usage Certificate” and arrangements will be made for you to pick up and return the iron lung and trailer.
  2. At least one month prior to your event, order the following items to ensure that your will have enough information available for the public.:
  3. End Polio Now Pins (available online through RI Catalog – 100 pins/$50)
  4. Pop-Up Polio Coin Boxes (available online through RI Catalog ) $3.00 Each
  5. End Polio Now Poster (available online through RI Catalog) FREE
  6. Rotary Bumper Stickers (order from the RC of Del Mar) at the following URL; http://www.delmarrotary.org/bumper.html
  7. $200 Million Challenge Brochures (call the RI publications department to order in bulk)
  8. $200 Million Challenge Donation envelopes (call the RI publications department to order in bulk.) These are free as are the Brochures.

6.  Pick up the iron lung / trailer and Handbook at the designated location. NOTE: The handbook contains all instructions for using the lung, etc., etc. It also has a zipped pocket in the front that has the keys to the trailer and the trailer storage box. DO NOT LOSE THESE KEYS!

  1. Complete the inventory and sign off on the Inventory checklist when you pick up the trailer and iron lung. You will be responsible for insuring that the inventory is complete when you turn it over to the next user.
  2. Enter your starting mileage in the mileage record in the handbook
  3. Turn the Iron Lung / Handbook / Trailer over to the next user.
  4. Complete the inventory and sign off on the inventory checklist when turning the iron lung over to the next user
  5. Ensure that the storage box is locked

c.  Ensure that the keys are in the pocket in the handbook

  1. Ensure that your ending mileage has been recorded in the handbook

After your event, ensure that the Event Final Report (included in this package) is submitted to the PDG Allan Davis – Rotary Club of Cranbrook Sunrise (District 5080) Polio Eradication Chair

Via email at or by phone at 250-426-5584 Or by mail at 1446 Hunter Rd., Cranbrook, BC, Canada, V1C 6V6

  1. . In addition, please email event photos to the


Iron Lung and Trailer Towing Requirements

In order to use the iron lung and trailer, your organization will need to pick up the trailer at the specified location and then return it to a pre-determined location. The requirements for towing the iron lung and trailer are as follows:

1.  Liability Insurance: Rotary Club of Cranbrook Sunrise (District 5080) does not have insurance that will cover liability in case of an accident while the trailer is being towed. When you request the use of the IL, you will need to tow the trailer. In order to do so, the vehicle which will be used to tow the trailer must have towing coverage for liability in case of an accident. This is a requirement and your request for use of the Iron Lung usage cannot be completed unless the vehicle towing the trailer is properly insured.

a.  Complete the Trailer Towing Form included in this package and submit it along with a copy of your insurance to Allan Davis (see address in other pages) at 250-426-5584.

2.  Gross Vehicle Weight: The vehicle which is used to tow the trailer and iron lung must have a minimum towing capacity of 3000 lbs. The trailer and iron lung along with the filled storage box are rated at 3000 lbs. Gross Vehicle Weight. Unless your vehicle (full size pickup truck or SUV) is rated at a minimum 3000 lb towing capacity, you will need to locate another vehicle to tow the trailer and iron lung or your request for use of the iron lung will not be approved.

3.  Trailer dimensions: The trailer is 16’ [4.8 m]long, 7’ 9” [2.33 m] wide and 7’ [2.1 m] high. It has a 2” [ 5 cm] ball and a wiring adapter. It is fully licensed in B.C. for highway travel. The iron lung is covered by a custom made shroud and secured to the deck with strapping.


Trailer Towing Information / Club Certification Form

Name of Rotary Club: / CLICK HERE to Enter Information
Date of Event: / CLICK HERE to Enter Information
Type of Event:
/ CLICK HERE to Enter Information
Name of Individual who will be towing the trailer: / CLICK HERE to Enter Information
Phone number of individual towing the trailer: / CLICK HERE to Enter Information
Email of individual towing the trailer: / CLICK HERE to Enter Information
Year, Make and Model of Towing Vehicle:
/ CLICK HERE to Enter Information
Vehicle’s License Plate Number: / CLICK HERE to Enter Information
Vehicle’s VIN Number: / CLICK HERE to Enter Information
Vehicle’s MINIMUM Towing Capacity rating: / CLICK HERE to Enter Information
Name of Insurance Company: / CLICK HERE to Enter Information
Name of Insurance Agent:
/ CLICK HERE to Enter Information
Phone Number of Insurance Agent: / CLICK HERE to Enter Information
Insurance Policy Number: / CLICK HERE to Enter Information


CLUB CERTIFICATION:

I, CLICK HERE to Enter name of club president certify that we, the Rotary Club of CLICK HERE to Enter Club Name understand that our use of the Iron Lung for our event is contingent upon having an appropriate vehicle to tow the trailer (with iron lung) with the required insurance. In addition, we confirm that we have completed an Event Insurance Form with Rotary International (copy attached)

We are submitting the above vehicle and insurance information along with the required copy of the vehicle insurance policy as proof of the requirements for towing the trailer and iron lung.

______
Signature of Club President Date

I, CLICK HERE to Enter name of individual towing trailer, confirm that the vehicle that I will use to tow the Rotary Club of Cranbrook Sunrise (District 5080) trailer and iron lung has the required vehicle towing capacity and insurance. A copy of the insurance is being submitted with this form as stated above.

______
Signature of individual who will tow trailer Date

E-mail this form along with a copy of the required vehicle insurance policy and a copy of the RI Club Insurance for this event and the Usage Request Form to:
PDG Allan Davis; Rotary Club of Cranbrook Sunrise (District 5080) Polio Eradication Chair
e-mail:


Application For Use of the Rotary Club of Cranbrook Sunrise (District 5080) Iron Lung

Name of Rotary Club: / CLICK HERE to Enter Information
District Number: / CLICK HERE to Enter Information
Date of Event: / CLICK HERE to Enter Information
Type of Event (please explain in detail): / CLICK HERE to Enter Information
Is this a fundraiser for Polio Eradication? / CLICK HERE to Enter Information
Are you doing any other fundraising at this event? / CLICK HERE to Enter Information
What is your anticipated attendance? / CLICK HERE to Enter Information
Is there a fee for this event? Amount? / CLICK HERE to Enter Information
Will there be a guest speaker? Name? / CLICK HERE to Enter Information
How many Rotary volunteers will be involved? / CLICK HERE to Enter Information
Are you partnering with another organization? / CLICK HERE to Enter Information
Is this a multi-club event? / CLICK HERE to Enter Information
Name of individual in charge of event: / CLICK HERE to Enter Information
Phone Number of individual in charge: / CLICK HERE to Enter Information
Email of individual in charge: / CLICK HERE to Enter Information
CLICK HERE to Enter Information

I, CLICK HERE to Enter name of club president, the president of the Rotary Club of CLICK HERE to Enter club name, request the use of the Rotary Club of Cranbrook Sunrise (District 5080) Iron Lung (with trailer) on the date(s) specified for the event(s) explained above. Included with this request form are the required Trailer Towing documents and insurance forms.

______
Signature of Club President Date

Return this form along with a copy of this Usage Request Form along with the Trailer Towing Form along with the required vehicle insurance policy and a copy of the RI Club Insurance for this event to:
PDG Allan Davis
Rotary Club of Cranbrook Sunrise (District 5080) Polio Eradication Chair
Or by email to:
Or by Mail to: 1446 Hunter Rd., Cranbrook, BC, Canada, V1C 6V6


Iron Lung Usage Report

Rotary Club of: CLICK HERE to Enter Information

Date(s) Iron Lung was used: CLICK HERE to Enter Information

Please describe, in detail, how you used the iron lung: CLICK HERE to Enter Information

How many were in attendance: CLICK HERE to Enter Information

How much money did you raise for Polio?: CLICK HERE to Enter Information

Which of the following Polio items did you have available and use?:

·  Polio Pins: CLICK HERE to Enter Information

·  Polio Brochures: CLICK HERE to Enter Information

·  Polio Contribution Envelopes: CLICK HERE to Enter Information

·  Polio Bumper Stickers: CLICK HERE to Enter Information

·  Other (please explain): CLICK HERE to Enter Information

Please provide feedback on your use of the iron lung / trailer so we can continue to improve on its use by our clubs: CLICK HERE to Enter Information

Please complete this form within a week following your use of the iron lung and return it to:

PDG Allan Davis
Rotary Club of Cranbrook Sunrise (District 5080) Polio Eradication Chair
Email:
Or mail to: 1446 Hunter Rd., Cranbrook, BC, Canada, V1C 6V6