LifeWorksMentoring.org

LifeWorks Bike Trip Participant Registration

Activity: LifeWorks Beach Bike Ride

Date & Time: Sunday, March 30, 2008, 11:30am

Please take the time to answer each question, all are required.

Participant Information

Name:
	(First)	(Last)

Address:
	(Address)	(City)	(State)	(Zip)

Home Phone:

Cell Phone:

E-Mail Address:

Height:

Date of Birth:

Gender (check one or more):
Female
Male
Transgender FTM
Transgender MTF
Genderqueer
Other:

Sexual Orientation (check one or more):
Lesbian
Gay
Bisexual
Queer
Not sure
Other:

Race/Ethnicity (check one or more):
Black/African Descent
Latino/Hispanic Descent
Native American
Asian or Pacific Islander
White/European Descent
Other:

Registration Information

In addition to this registration form you need to complete a full application including a legal waiver, photo release, and medical release forms. These forms cannot be completed online because they need to be printed out and signed. If you are under 18 they must be signed by your Parent or Guardian. None of these forms make any reference to sexual orientation or LGBTQ issues so if you’re not out to your parents, that’s okay. If you are worried about talking to your parents about this program, please contact us, we can help. Your full application is due by Saturday March 15th - space is limited so please turn in your application on time!

Please check below how you would like to receive a copy of the full application
I'm printing it myself, I've downloaded it from the website
Please mail it to my mailing address
Please fax it to this fax number:
I would like to come to the office to fill it out on this date:

Equipment Information

Note: you can NOT participate in LifeWorks Bike Rides without a helmet

I need to borrow a bike

I need to borrow a helmet

This is the initial registration form so that we can have your contact information and know that you are interested. Please understand that spaces are limited and submitting this form does not guarantee that you can participate. Each participant must fill out a full printed application including a medical form and legal waiver, and we have a limited number of bicycles and helmets to loan out.

Thanks for registering! After this form is received we will contact you to assist you with the full application. If you have any please contact Dan Dumont, Program Manager at ddumont@lifeworksmentoring.org

Privacy Statement | Copyright