Registration Form
2010 Greenbrier Valley Wheels of Hope Ride
Saturday, July 17th
Greenbrier County, Lewisburg, WV
Name: ____________________________________
If under 18, parents/guardian's signature: _______________________________
Street Address: ________________________________________________
City: ____________________________ State: ___________ Zip Code: ___________
Phone #: (_____)_____________ Email: __________________________________________
Age: ___under 18 ___18-29 ___30-49 ___50-69 ___70+
Emergency contact name: ________________________________ phone: (____)___________
Are you staying overnight in the Lewisburg area? |
Yes, Camping | _____ | Where? _______________________ |
Yes, Hotel | _____ | Where? _______________________ |
No | _____ | |
How many miles do you plan to bicycle?
____ 21 miles ____ 56 miles ____ 86 miles
$_________ Registration ($45.00 after July 10th)
$_________ Additional donation (all are greatly appreciated by those in need)
$_________ Total
Method of payment: ____ Personal check ____ Cash
All checks should be made to GVBC-- Wheels of Hope.
Mail to 211 W. Randolph St., Lewisburg, WV 24901.
Pre-Registration is closed. You may print and fill out this form and bring it with you to the event.
Thank you.
For further information contact Bill Zahuranec, Ride Organizer, at 304-645-5807,
or email billz73@gmail.com, or visit http://www.lewisburg.org/hope.
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