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PARTICIPATION APPLICATION FORM

Register As: Blader Cyclist
First Name:
Last Name:
Mailing Address:
City:
Postal Code:
Phone:
Alternative Phone:
E-mail:
Date of Birth: (D/M/Y)
Sex:
Medical Conditions:

   (Please specify ANY

   conditions, or concerns)
Emergency Contact: (Name)
Emergency Contact Phone Number:
T-Shirt Size:
**By submitting the following information, I understand that I am responsible for the $25 application fee by the deadline: June 15th 2006. I understand that it is my responsibility to raise a minimum if $250. I also acknowledge that I enter this event of my own accord, and will follow all regulations outlined by the "A Blade to Consider"

Copyright © 2006 [A Blade to Consider]. All rights reserved.

Revised: May 22, 2006

 
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