Register for the Ride or Walk to Remember

I am registering to:   Ride   Walk   Volunteer

Are you participating as a team? Yes No

Team Name:

Note: Every person must complete their own registration form and meet all registration and pledge requirements.

$20 registration fee required for all participants including volunteers to cover rider and walker supports, rest areas, food, entertainment, and an event T-shirt.

$100 minimum in pledges is required at registration on day of the Ride or Walk to Remember.
I want to include my pledges with my Registration Fee (minimum $120)
I will bring my pledges on day of event

My T-shirt size is: S   M   L   XL   XXL

Youths under the age of 18 must have parental permission to participate. Youths under the age of 13 must be accompanied by parent or guardian.
Ages 13-18: please click here to download permission slip. Please have parent or guardian sign it and bring it to the event or mail it in to the address below.
Ages 12 and under will be accompanied by:
     Parent Name:
     Guardian. Name:
            Relationship:

Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone:

In Dedication of

I am doing this in dedication to:
I would like to submit a short story in remembrance:
Note:256 Character Limit

Health Information

Medical Service Plan Name:    Plan number:

Note: you are responsible for producing your own medical insurance while participating in the "Ride or Walk to Remember".

Please list any medical or allergic conditions we should be aware of including related medications:

Confirmation and Limitation of Liability
The above name, in registering to be a participant in the 'Ride or Walk to Remember 2009' (referred to as "Ride 2009"), to be conducted September 6, 2009, by the Simon Project, hereby confirms and agrees as follows:

• I acknowledge that Ride 2009 will require strenuous physical activity and endurance and confirm that I am physically fit and will have trained sufficiently to participate. The Simon Project reserves the right to restrict your participation in the case of medical issues that would affect your safety.
• I agree to observe all the rules of the road and to act in such a way as to be responsible for my own safety at all times during Ride 2009.
• I grant full permission to the Simon Project to use any likeness of me participating in any Ride 2009 activity without obligation or liability to me.
• In consideration of the acceptance of my registration to Ride 2009, and on behalf of my dependents, heirs and any representatives, I release and discharge the Simon Project and any and all sponsors of Ride 2009 and their directors, officers, agents and employees (collectively referred to as the "organizers"), jointly and severally and hold and save them harmless from any and all actions, claims, demands, liabilities, loss, damage, injury or expense of any kind, including lawyer's fees which may result by reason of my participation in any activity related to or arising from Ride 2009, whether resulting from the negligence of the organizers or otherwise.