Words Into Deeds OutSpokin Taitem High Gear Gezers DSP Shows Homer Ileus IC Old Farts Team Sage Team Sage! Team GrammaTech STAP Bacchus Brewing Co. Wheels Up Rider Registration 9/8/2018 About you First Name Last Name Email Date of Birth * You cannot register online because you will be under 14 years old on the day of the ride. Please email firstname.lastname@example.org if you have any questions. Gender MFT Existing Medical Conditions? YesNo List of Conditions Contact Info Phone Number Street Apt / Suite City State New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Accompanying Adult Rider Full Name Date of Birth Email Phone Number Emergency Contact * Your emergency contact cannot be another rider. Full Name Relationship Phone Number About the Event Miles you will ride 1425426990102Indoor Are you in a team? YesNo Team Name Are you the team captain? YesNo Accept T-Shirt and gifts? YesNo T-Shirt Size Women's SmallWomen's MediumWomen's LargeWomen's X-LargeMen's SmallMen's MediumMen's LargeMen's X-LargeMen's XX-Large Are you a first time rider in the Ride? YesNo How many times have you ridden prior? Will you be attending 6pm dinner at Stewart Park? YesNo * You and one guest are included in your registration fee. Additional guests are $8.00 each (pay at dinner). Total number of dinner guests including yourself Other How did you hear about the ride? Training Notify me of about training rides. ARFL Sign I would like to display an ARFL sign for my yard. Sponsorships I would like to learn more about Sponsorship Opportunities. Other Events I would like to receive information about other STAP events. Registration Fee & Fundraising Fundraising In addition to the registration fee, I understand there is a minimum $300 fundraising requirement. In addition to the registration fee, I understand there is a minimum $100 fundraising requirement. 100 In addition to the registration fee, I understand there is a minimum $100 fundraising requirement. 100 Registration Fee $ 25 25 25 Discount Code YesNo Waiver I have read and agreed to the rider waiver. You had errors on your form. Please fix them and re-submit. A confirmation e-mail will be sent to you after you have paid the registration fee.