2009 Rider Entry Form Rider Name:________________________________ Rider Age:_______ Gender:_______ Address:__________________________ City, State, Zip:__________________________ Phone: (daytime)________________________Phone:(evening)________________________ Email:___________________________________________________________________ Hotel Room Assignments: Roommate Preference (please circle): Yes No Prefer Single If Yes, whom?:______________________ Fundraising Promise: Entry Fee, Donation and Pledge Disclosure: I have read the above statements and wish to enter as a rider in Cycle for Sight 2009: ________________________ ________________________ _____________ Checkout: Registration Fee: --------------------------------------------------------------------------------------- $100.00 Cycle for Sight 2009 Jersey: (Free)----------------------------------------------------------------- $0 Extra Cycle for Sight 2009 Jersey: ($65)---------------------------------------------------------- $_______ Additional Contribution:-------------------------------------------------------------------------------- $_______ Total: $_______ Please make checks payable to: Cycle for Sight Mail checks and registration form to: Cycle for Sight
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