Wediko's 5th Annual Century Ride Registration Survey

1. Registration for Wediko's 5th Annual Century Ride

You are registering for the 5th Annual Wediko Century Ride. The ride is a 100-mile (62 mi & 25 mi routes available) bike ride from Wediko's New Hampshire campus to our Boston office. All proceeds will be directed towards the "greening" of Wediko, including the redevelopment of hydropower on the Wediko dam of Black Pond. When we save money on energy costs, more money is available to help children and families.
All participants are required to raise a minimum of $1000*, but don't worry- we're with you every step of the way!

DATE: Saturday September 15, 2012(dinner/lodging available on Friday, September 14th in NH)
LOCATION: Start at Wediko's NH campus in Windsor, NH and finish at Wediko's Boston office (*high school & undergraduate students commit to raise $500)

1. Please enter the required information below

Please enter the required information below Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Cell Phone Number:

2. Your sex?

Your sex? Female

Male

3. Will you be 18 years or older on September 15, 2012?

Will you be 18 years or older on September 15, 2012? Yes

4. How did you hear about the ride?

How did you hear about the ride? I work or used to work at Wediko

I work in a school & saw a brochure

A friend or family member at Wediko

An email

Brochure in a store, etc

Online calendar

Online forum

Wediko Website

Wediko Newsletter

Other

5. All riders receive a cotton Wediko Century Ride t-shirt. Please indicate your t-shirt size below(sizes are unisex).

All riders receive a cotton Wediko Century Ride t-shirt. Please indicate your t-shirt size below(sizes are unisex). small

medium

large

x-large

xx-large

6. All riders also recieve a cycling jersey, made of technical fiber. Please indicate your size below. (Please keep in mind that these jerseys are typically worn as close fitting garments. If you would prefer a looser fit, please order a larger size.)

All riders also recieve a cycling jersey, made of technical fiber. Please indicate your size below. (Please keep in mind that these jerseys are typically worn as close fitting garments. If you would prefer a looser fit, please order a larger size.) I don't need a new one, I will wear my jersey from a previous ride

womens x-small

womens small

womens medium

womens large

womens x-large

womens xx-large

womens xxx-large

mens x-small

mens small

mens medium

mens large

mens x-large

mens xx-large

mens xxx-large

7. How do you plan to get to the start, Wediko's campus in Windsor, NH?
(If you are not sure, please give us your best guess. You can change your plan up until three weeks before the event. Please keep in mind that the ride ends 100 miles away. We can not guarantee that your car, if brought to the start, can be delivered to Boston)

How do you plan to get to the start, Wediko's campus in Windsor, NH? (If you are not sure, please give us your best guess. You can change your plan up until three weeks before the event. Please keep in mind that the ride ends 100 miles away. We can not guarantee that your car, if brought to the start, can be delivered to Boston) My own transportation, Friday night

My own transportation, Saturday morning

Transportation provided from the Boston office on Friday afternoon(4:30pm-sharp departure)

If by your own transportation, will you leave a car at the start or will you be dropped off?

8. Will you need a ride back to the start, Wediko's NH campus in Windsor, NH?

Will you need a ride back to the start, Wediko's NH campus in Windsor, NH? Yes

Not sure (please specify)

9. Will you stay with us on Friday night on Wediko's campus?
(If you know Wediko, then you know that the accommodations provided can be considered 'rustic'. Also, guests would need to provide their own towel, toiletries, pillow and bedding/sleeping bag.)

Will you stay with us on Friday night on Wediko's campus? (If you know Wediko, then you know that the accommodations provided can be considered 'rustic'. Also, guests would need to provide their own towel, toiletries, pillow and bedding/sleeping bag.) No

Yes

If yes, any additional guests? How many?

10. If you are staying on the Wediko setting Friday night, what is your sleeping preference?

If you are staying on the Wediko setting Friday night, what is your sleeping preference? No preference

Group bunks in a cabin with fellow riders

Prefer private room if possible

I am a loud sleeper, and for the comfort of others it would be helpful to have a private room

Strongly prefer a private room

Other (I have my own arrangements but I will be coming to dinner & the Friday night program)

11. How many miles do you plan to ride?

How many miles do you plan to ride? 100 miles

100 kilometers (62 miles)

25 miles (approximately, from the last rest stop)

12. This event's success is dependent not only on our riders, but on our volunteers as well!
Do you know someone who would like to volunteer the weekend of the event? Please pass along their name and email or phone number so that we can contact them!

This event's success is dependent not only on our riders, but on our volunteers as well! Do you know someone who would like to volunteer the weekend of the event? Please pass along their name and email or phone number so that we can contact them! No

Yes

Please include his/her name and contact information. Thank you.

13. Do you know someone who may be interested in riding? Please let us know how to contact him/her/them and we'll send an invitation!

Do you know someone who may be interested in riding? Please let us know how to contact him/her/them and we'll send an invitation!

14. Please give us your emergency contact information.

Please give us your emergency contact information. Name:
Address:
City/Town:
State:
ZIP:
Relationship:
Email Address:
Cell Phone Number:

15. I understand that by registering and agreeing to ride in the 5th Annual Wediko Century Ride on September 15, 2012, I am agreeing to raise a minimum of $1,000 for Wediko. (Don't worry-we will support you every step of the way! You will also have access to online giving. Please contact Kate Patton Regal if you are concerned at any time about your ability to fundraise- kregal@wediko.org)

I understand that by registering and agreeing to ride in the 5th Annual Wediko Century Ride on September 15, 2012, I am agreeing to raise a minimum of $1,000 for Wediko. (Don't worry-we will support you every step of the way! You will also have access to online giving. Please contact Kate Patton Regal if you are concerned at any time about your ability to fundraise- kregal@wediko.org) Yes

Yes, but I am a high school or undergraduate student with a $500 commitment.

Other

16. We would like your permission to use century ride images (pictures, videos) for publicity purposes - such as newsletters, Wediko's Facebook page, website, brochures, etc. If you would be willing to release your image please check the appropriate box below.

We would like your permission to use century ride images (pictures, videos) for publicity purposes - such as newsletters, Wediko's Facebook page, website, brochures, etc. If you would be willing to release your image please check the appropriate box below. I CONSENT to the use by Wediko Children's Services, Inc. of any photographs, videotapes, motion pictures, images or other physical representations of myself whether prepared by or for Wediko, in materials that describe, promote, explain, sell or otherwise depict the Wediko Century Ride.

I DO NOT CONSENT Wediko Children's Services, Inc. to use my image.

Wediko's 5th Annual Century Ride Registration

1. Registration for Wediko's 5th Annual Century Ride

1. Please enter the required information below

2. Your sex?

3. Will you be 18 years or older on September 15, 2012?

4. How did you hear about the ride?

5. All riders receive a cotton Wediko Century Ride t-shirt. Please indicate your t-shirt size below(sizes are unisex).

6. All riders also recieve a cycling jersey, made of technical fiber. Please indicate your size below. (Please keep in mind that these jerseys are typically worn as close fitting garments. If you would prefer a looser fit, please order a larger size.)

8. Will you need a ride back to the start, Wediko's NH campus in Windsor, NH?

9. Will you stay with us on Friday night on Wediko's campus? (If you know Wediko, then you know that the accommodations provided can be considered 'rustic'. Also, guests would need to provide their own towel, toiletries, pillow and bedding/sleeping bag.)

10. If you are staying on the Wediko setting Friday night, what is your sleeping preference?

11. How many miles do you plan to ride?

12. This event's success is dependent not only on our riders, but on our volunteers as well! Do you know someone who would like to volunteer the weekend of the event? Please pass along their name and email or phone number so that we can contact them!

13. Do you know someone who may be interested in riding? Please let us know how to contact him/her/them and we'll send an invitation!

14. Please give us your emergency contact information.

16. We would like your permission to use century ride images (pictures, videos) for publicity purposes - such as newsletters, Wediko's Facebook page, website, brochures, etc. If you would be willing to release your image please check the appropriate box below.

9. Will you stay with us on Friday night on Wediko's campus?
(If you know Wediko, then you know that the accommodations provided can be considered 'rustic'. Also, guests would need to provide their own towel, toiletries, pillow and bedding/sleeping bag.)

12. This event's success is dependent not only on our riders, but on our volunteers as well!
Do you know someone who would like to volunteer the weekend of the event? Please pass along their name and email or phone number so that we can contact them!