Required by Date:

Chapter Name:

Chapter Address:

Chapter Contact Person:

Phone: Fax: Email:

Date of Event/Program:

Name of Event/Program:

Type of Event (i.e. skiing, cycling, fundraiser, camping):

Please identify safety equipment/precautions being used during the event (i.e. life vests):
             

Event Location:

CERTIFICATE HOLDER/ADDITIONAL INSURED:
*Include Relationship to Event (i.e. Sponsor, Landowner, Event Site, Equipment Provider)

Name:

Address:

Relationship to Event:

Additional Insured Contact Name:

Special Instructions (i.e. special language required by the additional insured):

Unless otherwise requested, the certificate/endorsement will be emailed directly to the requesting chapter.

Email requests, Allowing 21 days for processing to dsusa@dsusa.org

To be completed by National Office, Disabled Sports USA