Due to Increased Security Measures on the Naval Support Activity (NSA) Installation In

FEW ADULT SPECIAL OLYM PICS GAMES 2015 VOLUNTEER SECURITY FO RM

. You must present a valid picture identifica tion. . The Guards will NOT grant access to any . Due to increased security measures on the Nav one whose name is not on the attendance l al Support Activity (NSA) Installation in Mec ist. Therefore, it is important that you sub hanicsburg, we are requiring ALL volunteers a mit the requested information by the due d nd ALL persons accompanying the athletes an ate. d/or attending the event to submit the requeste . Vehicles are subject to inspection on the d information by the due date listed below. Fai NSA Installation. lure to submit the completed attached form in . Parking is limited to the designated areas. the allotted timeframe will result in denial of a You will be directed to the parking area u ccess to the NSA Installation. pon arrival. . Entrance to the NSA Installation is ONLY per . NSA Installation access will be confined t mitted through the Main Gate off of Route 58 o the event areas ONLY. 1 (5450 Carlisle Pike). . Pursuant to the Internal Security Act, Alco . Buddies will be assigned a specific athlete ahe hol, Drugs and Weapons are NOT permitt ad of time. If you already have an athlete in mi ed on the NSA Installation. nd, please request his/her name on the attache . Under the current Force Protection Condit d form. ions, the NSA Installation can host this ev ent. Should the current status change, the Adult Special Olympics may need to be re RETURN FORM BY APRIL 3, 2015 located or cancelled. Notification will be made to AM 580, WHP Harrisburg Radio; TO: FM 104 WNNK Harrisburg Radio; WITF Radio; TV ABC Ch. 27; TV WGAL Ch. 8; Andre Harrell, Code N 97122, TV WHP Ch. 21; and Fox TV Ch. 43. NAVSUP-WSS, Building 311-2, 5450 Carlisle Pike, P.O. Box 2050 Mechanicsburg, PA 17055-0788

OR FAX TO: 717-605-1225

KEEP THIS INFORMATION AS A REMINDER OF THE R EQUIREMENTS FOR DAY OF THE EVENT April 25, 2015 ~ Adult Special Olympics ~ Area “M” Volunteer Registration & Security Information Instructions: Complete the 6 steps below – submit form by April 3, 2015 1. Volunteer/Escort Information 5. Volunteer Signature (required by all FULL NAME: ______volunteers) DATE OF BIRTH: ______I am 18 years of age or older and I understand that: Upon request, I can be asked to submit an application for a ___ Athlete Escort (Not a Buddy) ____ Parent criminal background check; the information that I have provided may be verified, and I give permission to Special Olympics to ___ Volunteer Worker ___ Other (Please Specify) ______make inquiry of others concerning my suitability to act as a Special ADDRESS: ______Olympics volunteer; in the course of volunteering for Special Olympics, I may be dealing with confidential information and I CITY: ______STATE: ___ ZIP: ______agree to keep said information in the strictest confidence; the relationship between Special Olympics and volunteers is an at will TELEPHONE: ______agreement, and that it may be terminated at any time without cause EMAIL: ______by either the volunteer or Special Olympics; I grant Special Olympics permission to use my likeness, voice, and words in (If on-base indicate Code: ______and Ext: ______) television, radio, film, or in any form to promote activities of Special Olympics. 2. Security information I affirm that I have read the above and that the information I have given is true and complete. (If at any time the information Due to increased security measures on the Naval Support Activit provided is found to have been knowingly falsified, you will be y (NSA) Installation in Mechanicsburg, we are requiring ALL v disallowed from volunteering for any program accredited by olunteers and ALL persons accompanying the athletes and/or att Special Olympics Pennsylvania.) ending the event to submit the requested information by the liste d due date. Failure to submit the completed attached form in the Signature: ______allotted timeframe will result in denial of access to the NSA Inst Date: ______allation. Current DOD Employees/Military Personnel: ____I have a c 6. Return this Form by April 3, 2015. urrent badge for NSA Installation access and will display it to ob tain entrance to the event. Mail to: Andre Harrell, Code 97122, NAVSUP-WSS, Bldg 311-2, 5450 Carlisle Pike, P.O. Box 2050, Mechanicsburg, Vehicle Information PA 17055-0788 Or, Fax to: 717-605-1225 Year/Make/Model ______License #______* Reminders for the day of the event *

You must have photo identification and your na 3. Volunteering for: (Indicate 1st and 2nd choices) me must be on the list. Guards will not permit anyon ___BUDDY ___ Photography ___ Soccer e inside the gate without either: a proper badge or a photo I ___ Basketball ___ Registration (Athlete) ___ Softball Skills ___ Bowling ___ Registration (Volunteer) ___ Softball Throw D and pre-registration. ___ Cleanup ___ Ribbon Writing ___ Swimming - Cars are subject to inspection ___ Long Jump ___ Setup ___ Track Events - Parking will be limited to certain areas. You will be directe Other:______d where to park. Base access will be confined to the event a reas only; pursuant to the internal security act, alcohol, drug Assigned/Requested Athlete: ______s and weapons are not permitted on a military installation. (Note: cameras are permitted in the event areas only!) Circle T-shirt Size: S M L XL 2X 3X 4X 5X Under the current force protection conditions, the installation can host this function. In the event the current 4. Emergency Point of Contact: status changes, games may need to be relocated or canceled. Notification will be made to AM 580 WHP Hbg. Radio; FM Name: ______104 WNNK Hbg. Radio; WITF radio; TV ABC Ch. 27; TV WGAL Ch. 8; TV WHP Ch. 21; and FOX TV Ch. 43. Phone: ______Address: ______*************** Contact Samad Syed, Event Director (717-605- ______6283), for information concerning the event. Relationship to Volunteer: ______

For Registration Questions please contact Andre Harrell, 717-605-5062 ([email protected]) Dorethea Smith-Jenkins, 717-605-3117 ([email protected])