Registration Form:

Please mail form to:

Pedal For Patients
St. Lukes Msti

1118 NW 16TH ST

Fruitland  ID   83619
www.Pedalforpatients.com

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Name

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Address

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City / State / Zip

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Phone

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E-mail

Ride

Late fee of $10 after Aug 23
 

o 20 miles $20 ($30)
o 20 miles Family with children $15/adult and$10/child early reg. only
o 40 miles $30 ($40)

o 68.7 miles $35 ($45)

o 100 miles $40 ($50)

o Under 13 years $15 ($25)

o Additional meal tickets for non riders
 _________x $5 each....................... $________

Chosen ride................................. $________

Additional contribution.............. $________

Grand Total.................................. $________