Registration Form:

Please mail form to:

Pedal For Patients
530 E Main St    

Weiser Idaho

 83672
www.Pedalforpatients.com

_______________________                                                           Name

_______________________                                                          Address

_______________________

City / State / Zip

_______________________

Phone

_______________________

E-mail
Age___________  

Ride

Late fee of $10 after Aug 23
 

o 20 miles $20 ($30)
o 20 miles Family with children $15/adult and$10/child Mail early reg. only
o 40 miles $30 ($40)                     Tshirt size  XS S M L XL    

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....................... $________         MAKE CHECKS OUT TO ST ALPHONSUS

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

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

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