Ride with Me for Autism -- Bike
Ride Registration Form
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PRINT |
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Name:
_______________________________________________________
Email:
_______________________________________________________
Address:
_____________________________________________________
City: _________________________
State _______ Zip ________________
Phone: ___________________________
Age on Day of Ride: __________
Gender: M ___ F
___ T-shirt Size (circle
one) Small Medium Large X-Large
Emergency Contact Name:
________________________________ Phone: _________________
Choose your Ride distance:
100 Km / Metric Century _____ 29 Mile _____
10 Mile _____ Family Fun Ride _____
Registration Fee s:
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The registration fee (age 13 and up) is $25
until February 12, 2010 and $30 after February 12, 2010. * |
| The children's (12 and
under) registration fee is $10 until February 12, 2010 and $15 after
February 12. 2010. Child t-shirt only available in Adult Small. * |
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The minimum pledge to ride is $100 (the
registration fee does not count towards the fundraising pledge.) Anyone
can support your effort by donating in your name at:
http://www.active.com/donate/ridewithme
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Be a Team Captain |
| Form a team of two
riders or more by registering online at
http://www.active.com/event_detail.cfm?event_id=1797690 and then
click on "create a team" -- or call (904)771-6707. |
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Will you be riding on a team? ___Yes ___ No
--- If Yes, what team?_________________________ |
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Fundraising Pledge to Participate in Ride
______$100 per rider age 18 and up:
$___________ ______$250 per family $____________
Amount Enclosed: $_______
(Registration fee) + _______ (Fundraising) = Total enclosed $ __________ |
| On the day of the ride,
all riders must sign and bring the waiver/release to check-in. It can be
downloaded at:
www.ridewithmeforautism.org
( then click the link for the Waiver page)
**HELMETS REQUIRED for all cyclists** |
| Online Registration --
Secure online registration at
http://www.active.com/event_detail.cfm?event_id=1797690
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| For additional
details for Ride with Me for Autism, go to:
http://www.ridewithmeforautism.org
or call (904)771-6707 |
| For Donations and to
set up your own fundraising page, visit:
http://www.active.com/donate/ridewithme |
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*In order to receive an
official Ride with Me t-shirt, you must register online or have your
registration application in our office by February 26, 2010
Mail in
Registration : Make check or money order payable to:
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Jessica Green Foundation, Inc.-Ride,
8444 Rock Knoll Drive, Jacksonville, FL 32221 |
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Click to return to Ride
with Me for Autism page |
