Registration Form:

Please mail form to:

Noa Towner

530 E Main

Weiser ID   83672

www.Pedalforpatients.com

_______________________

Name

_______________________

Address

_______________________

City / State / Zip

_______________________

Phone

_______________________

E-mail

Age____ Sex:  o Male  o Female

T-shirt size: S  M  L  XL

Ride

Late fee of $10 after Sept. 1

o 20 miles  $20 ($30)

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.............. $________

Extra T-shirts $10........................ $________

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