Charity Ride On-Line Entry Form

SEPTEMBER 26, 2009

Check-in and registration will be from 8:00am to 10:30am the day of the ride. All riders and passengers will be required to sign a waiver at that time in order to ride. Riders with "paid in full" registrations by August 15, 2009 will be guaranteed a free charity t-shirt. All registered participants will be provided lunch the day of the ride.

Riders Name:

   Address:

 

 

 City:

 

 

State:

 

 

Zip:

Rider Fee

 $15.00

Phone:

 

 

Cell:

 

 

** E-mail:

 

 

 

If no passenger leave blank

 

 

Passenger's Name:

   Address:

 

 

City:

 

 

State:

 

 

Zip:

Passenger Fee

 $10.00

Phone:

 

 

Cell:

 

 

**E-mail:

 

 

** We value your privacy.  Your E-mail address will only be used to notify you of any changes to this event and or to notify you of future events and will not be sold or given to anyone for any other purpose without your permission.

After completion of form, click the Submit button below to send information. Do not hit Submit or Enter until you are ready to send your information.

Thanks you for your support

If you get an ERROR please email cprice@alittlewiggleroom.com with the pre-register info and to report this error.

Rider Fee

$15.00

Checks should be made payable to :

Passenger Fee

$10.00

ABATE Foundation

 

 

 

 

 
    Mail to:

A Little Wiggle Room

c/o Cindy Price

501 San Marcos Drive

Greenwood, IN 46142
 
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Last updated on Monday, 14. June 2010