Paying by check? Download instead (print, fill, send) *Items with an asterisk are required.
1. Personal Information
*Participating as:
--------------
Rider
Crew
*First Name
Middle Name
*Last Name
*Home Address
Unit #
*City
*State
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Northern Mariana Islands(MP)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
-----
Armed Forces Africa(AE)
Armed Forces Americas(AA)
Armed Forces Canada(AE)
Armed Forces Europe(AE)
Armed Forces Middle East(AE)
Armed Forces Pacific(AP)
*Zip Code
*Home Phone (no dashes)
Work Phone (no dashes)
Cell Phone (no dashes)
Date of Birth (you must be 18 or older to partcipate)
*Month--
1 2 3 4 5 6 7 8 9 10 11 12
*Day--
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
*Year--
1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986
*eMail Address
2. Recommend the Ride
Know anyone who would be interested in participating in The SMART Ride? Give us the info and we'll handle it from there! (we promise not to share or sell ANY information EVER)
First Name
Middle Name
Last Name
Home Address
Unit #
City
State
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Northern Mariana Islands(MP)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
-----
Armed Forces Africa(AE)
Armed Forces Americas(AA)
Armed Forces Canada(AE)
Armed Forces Europe(AE)
Armed Forces Middle East(AE)
Armed Forces Pacific(AP)
Zip Code
Company Name
Company Phone (no dashes)
Recommend as:
--------------------------
Sponsor
Participant
3. Emergency Contact Information
Please provide us with two emergency contacts.
*First Name
Middle Name
*Last Name
*City
State
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Northern Mariana Islands(MP)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
-----
Armed Forces Africa(AE)
Armed Forces Americas(AA)
Armed Forces Canada(AE)
Armed Forces Europe(AE)
Armed Forces Middle East(AE)
Armed Forces Pacific(AP)
*Relationship to participant
----------------------
Spouse
Partner
Friend
Sister/Brother
Parent
Grandparent
Relative
Other
*Home Phone (no dashes)
Work Phone (no dashes)
Cell Phone (no dashes)
First Name
Middle Name
Last Name
City
State
Alabama(AL)
Alaska(AK)
American Samoa(AS)
Arizona(AZ)
Arkansas(AR)
California(CA)
Colorado(CO)
Connecticut(CT)
Delaware(DE)
District of Columbia(DC)
Florida(FL)
Georgia(GA)
Guam(GU)
Hawaii(HI)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Iowa(IA)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Maine(ME)
Marshall Islands(MH)
Maryland(MD)
Massachusetts(MA)
Michigan(MI)
Minnesota(MN)
Mississippi(MS)
Missouri(MO)
Montana(MT)
Nebraska(NE)
Nevada(NV)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
New York(NY)
North Carolina(NC)
North Dakota(ND)
Northern Mariana Islands(MP)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Palau(PW)
Pennsylvania(PA)
Puerto Rico(PR)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Vermont(VT)
Virgin Islands(VI)
Virginia(VA)
Washington(WA)
West Virginia(WV)
Wisconsin(WI)
Wyoming(WY)
-----
Armed Forces Africa(AE)
Armed Forces Americas(AA)
Armed Forces Canada(AE)
Armed Forces Europe(AE)
Armed Forces Middle East(AE)
Armed Forces Pacific(AP)
Relationship to participant
----------------------
Spouse
Partner
Friend
Sister/Brother
Parent
Grandparent
Relative
Other
Home Phone (no dashes)
Work Phone (no dashes)
Cell Phone (no dashes)
4. Miscellaneous Information
*Gender
--
Male
Female
*T-shirt size:
--
M
L
XL
XXL
*Bike shirt size:
--
M
L
XL
XXL
I prefer vegetarian meals: Yes No
Have you ever participated in The SMART Ride before? (including Bike It and B.E.A.R. It)
--
1 year
2 years
3 years
4 years
5 years
SPECIALTY CREW, list your talents:
Personal Quote Here's your chance to broadcast your message of why you're partcipating in this ride. Your words will be used on the web and possibly in future print materials. Keep your statement under 3 lines.
How did you hear about the ride? (hold down CTRL to select multiple sources)
Newspaper
Bike Shop
Doctor's Office
Advertisement
Radio
TV
Friend/Family
Work
Benefiting Agency
Club
Poster
Outreach Venue
Past Participant
Other
5. Housing Information
(optional)
6. Registration Payment
All information is sent via a secure (SSL) connection.
Your $75 registration fee is non-refundable and non-transferable. Riders, registration fees do not apply toward your $1,250 fundraising minimum.
CHECK:
To pay your registration fee by check, you will need to print the PDF version of this form and fill it out offline. Please make checks payable to The SMART RIDE and mail with that form to: The SMART Ride, 1314 East Las Olas Boulevard, Suite 302, Fort Lauderdale, Florida, 33301-2334.
CREDIT CARD:
To pay by credit card or direct deposit, proceed to step 2 below.
6. Participant Agreement
I Disagree with the Above Listed Conditions
I Agree to the Above Listed Conditions