2010 Torch Ride registration

1. Contact Information & Background

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* 1. Please enter your contact information.

Name:

Work Address:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number:

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* 2. What is your t-shirt size? (Check one)

Small

Medium

Large

X-Large

2X-Large

3X-Large

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* 3. Please enter your birthdate. (Optional)

Birthdate

Date

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* 4. Please enter your gender. (Optional)

Male

Female

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* 5. I understand that the Special Olympics State Office must receive my $35 registration fee per motorcycle/$15 additional rider by September 10th to receive the free raffle ticket and free souvenir t-shirt.

I agree

Thank you for completing the Torch Ride to benefit Special Olympics Indiana online registration.

The top fundraiser at pre-registration will be the lead rider for the Torch Ride. If you would like to use our fundraising Web site, visit www.firstgiving.com/soindiana.

Please make checks payable to: Special Olympics Indiana, Attention: Torch Ride, 6100 West 96th Street, Suite 270, Indianapolis, IN 46278.

Thank you for your support of Special Olympics Indiana and the Law Enforcement Torch Run.