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