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Pedaling for Prevention Family Fun Day Registration
Registration Information
First Name*
*
Last Name*
*
Additional Family Members Registering (one per line)
Address 1*
*
Address 2
City*
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State*
*
Zip Code*
*
Phone (xxx-xxx-xxxx) *
*
Cell Phone (xxx-xxx-xxxx)
Email*
*
Emergency Contact *
*
Emergency Phone *
*
Select Events *
50 Mile Bike Tour
20 Mile Bike Tour
5K Fun Ride/Walk
Waiver
In consideration of being accepted as a Pedaling for Prevention participant, I, the undersigned, intending to be legally bound, do hereby for myself, my heirs, executors, administrators or assigns, waive, release and forever discharge any and all rights and claims I may have against the Coalition for Healthy Communities and NCADD of Middlesex County, Inc., the officers, members, sponsors and any other persons connected with the Pedaling for Prevention, for any liability from my injury, illness or death sustained as a result of my participation in any activities associated with the Pedaling for Prevention event. I warrant that I am in good health and physical condition and have no disabilities that will affect my ability to participate. If a Rider, I am competent to ride safely and I agree to abide by all traffic laws of the State of New Jersey. My bicycle equipment is in good, safe working order. I agree to wear an approved helmet while riding on any of the Pedaling for Prevention bike tours. I understand this waiver will be enforced under and interpreted by the laws of the State of New Jersey. I agree to allow the use of my photo/video for promotional purposes regarding the Coalition for Healthy Communities/NCADD of Middlesex County, Inc. and Pedaling for Prevention.
I Agree to the above waiver *
T-Shirts
Note: One shirt per registered participant
How many Small
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How many Medium
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How many Large
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How many XL
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Participants
Team Name *
How many Adults ($35)
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How many Students ($15)
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How many Seniors ($15)
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Additional Donation
Donation $ *
*
Total
Total Payment Due $
* = required fields
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