The SMART Ride 5 + Registration

*Items with an asterisk are required.

1. Personal Information

*Participating as:

*First Name

Middle Name

*Last Name

*Home Address

Unit #

*City

*State

*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

*Day

*Year

*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

Zip Code

Company Name

Company Phone (no dashes)

Recommend as:

3. Emergency Contact Information

Please provide us with two emergency contacts.

*First Name

Middle Name

*Last Name

*City

State

*Relationship to participant

*Home Phone (no dashes)

Work Phone (no dashes)

Cell Phone (no dashes)

First Name

Middle Name

Last Name

City

State

Relationship to participant

Home Phone (no dashes)

Work Phone (no dashes)

Cell Phone (no dashes)

4. Miscellaneous Information

*Gender

*T-shirt size:

*Bike shirt size:

I prefer vegetarian meals:
Yes No

Have you ever participated in The SMART Ride before?
(including Bike It and B.E.A.R. It)

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)

5. Housing Information

(optional)

Housing Request in Marathon
If the individual is not a rider or crew, the fee will be $125 for them to stay with us overnight in Marathon. Approximately 30 days prior to the ride you will be notified by e-mail of this approval and you will have 48 hours to make payment.	I would like to be housed with Rider or Crew Member:
Request for Private Villa in Marathon
All private rooms are located in Villas that sleep up to six people; the cost is $125. Upgraded rooms will be confirmed approximately 30 day out via e-mail and must be paid within 48 hours of receiving notice or will be released for sale to those on the waiting list.	I would like to request a private room: YES NO
Villa Roommate Request
All Villas sleep up to six people. If your list does not fill the Villa we will most likely fill that vacancy with another rider or crew in need of a roommate.	I would like to be in a villa with the following roommates: 1. 2. 3. 4. 5.

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

As a participant in The Southern Most AIDS Ride 5, I agree to the following:

Riders
To raise a minimum of $1250 in order to participate in this two-day bicycle ride, I agree to act in a responsible fashion when participating in this biking event, obeying all traffic laws as apply to bicycles. I will wear a Snell, ANSI, or STM-certified helmet during the ride and while participating in any and all training rides. I will always Ride with Safety as my number one objective.

Crew
I agree to be apart of the support system that assists the riders as well as, although not mandatory, to raise money by fundraising, thereby increasing the amount of overall dollars that will be given to the benefiting charities. I understand that my role in this event is crucial to the overall success and I will be willing to go the extra mile if called upon to ensure rider needs are met, and safety will always be the number one goal.
In addition as a participant, I agree to attend a Safety Session as offered prior to the start of the event. I understand that solicitation of this event is everyone’s responsibility and will try my utmost to help the ride grow by soliciting for riders, crew, and sponsors to ultimately help those in need with HIV/AIDS.

Waiver of Negligence & Release of Liability

By participating in The Southern Most AIDS Ride 4 in 2007, I understand this 175 mile non-competitive bicycle ride and related event, including but not limited to training rides. I understand that by participating I will be using public streets and facilities where many hazards exist and I am aware of and appreciate the risks that may result. I am voluntarily participating in this event with knowledge of the dangers involved and I agree to accept any and all risks. In consideration for being involved in this event, I agree to assume all risks and to release and hold harmless any of the Benefiting Organizations/Agencies, the producers and/or organizers any parent company, or public entities, and their affiliated organizations, all modes of transportation to and from the event, as well as sponsors, officials, participating clubs organizations or communities and their respective officers, directors, agents, employees and members who, through negligence, carelessness or an other cause might otherwise be liable to me.

I am physically capable of participating in the The Southern Most AIDS Ride 4 event. I have made any medical care provider who knows me and may be treating me for any physical infirmity, ailment or illness, aware of my involvement and I have their permission to partake in this event. I acknowledge that I, and no one else, am solely responsible for my personal health and safety, the condition of the bicycle I will be riding, and the personal property I bring with me. I will read the ride description and rules for participation in the The Southern Most AIDS Ride 4 event and will abide by all rules and regulations established by the organizers and the State of Florida.

I understand that my name, photograph, voice or likeness may be used by any of the organizers, beneficiaries, employees or affiliates. I consent to and authorize, in advance, such use and waive my rights of privacy I have in connection there within. I will provide proof of medical and accident insurance. If I do not provide this or do not have personal medical insurance or am not covered under any medical plan, I accept full responsibility for any costs incurred for medical treatment and evaluation. I understand that this is my responsibility to provide payment to any hospital, emergency response technician, emergency transport company, that may provide service to me as a result of injury or illness during the event. I will always keep SAFETY as my number one objective.

I have read and understand the contents. I certify that I am at least 18 years of age, I am aware that this is a release of liability and contract between me and persons and entities mentioned above and all of their respective officers, directors, employees, agents, volunteers, representatives, and I sign it of my own free will. In addition, I am aware that I will be asked to confirm my understanding of this agreement on the day of the event by signing another copy of this waiver, and the failure to do so will disqualify me from participating in the event without entitling me to any refund.

I Disagree with the Above Listed Conditions
I Agree to the Above Listed Conditions

The Southern Most AIDS/HIV Ride 5 (The SMART Ride) is under the financial administration of Broward House a 501(c) 3 non profit organization. All contributions are tax deductible to the fullest extent of the law. A copy of Broward House’s official charitable registration and financial information may be obtained from the Division of Consumer Services by calling toll free 1-800-435-7352.

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