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Registration Form Pigeon Lake Pedal Saturday, July 4, 2009
NEW!! *FREE REGISTRATION if $500 in pledges collected&submitted to Alberta Cancer Foundation by July 2, 2009!
Registration includes long sleeve t-shirt, snacks & BBQ lunch.
One PRIZE draw ticket for each $100 collected by event.
Name:__________________________________________________________________ Address:________________________________________________________________ City: ___________________________________Postal Code:______________________ Phone Number: ______________________Email:________________________________ Emergency Contact: _______________________________________________________ Alberta Health Care #:______________________________________________________ _______________ x $35 per person (free with $500 collected, submitted pledges by July2) $_______________TOTAL Payment by Cheque _____Cash _____Credit Card ____
Credit Card Type_____ # ____________________
Expiry mo___ yr_____ Signature __________________________ PARTICIPANT WAIVER: In consideration of accepting this entry. I hereby, for myself, my heirs, executors and administrators, waive and release any and all right or claim to damages I may have against the organizers of this event, their agents, representatives, volunteers, successors and assigns, sponsors and the Alberta Cancer Foundation, for any and all injuries I may sustain during the course of this event. Children under 13 must be accompanied by an adult for 60 km long ride.
X________________________________ Signature of participant
(if participant is under 18 years of age, waiver must be signed by parent or guardian).
TO REGISTER: 1. NEW Register online or Complete and sign this Registration form.
2. Pay Registration fee (*or submit $500 in donations by July 2, 2009 for FREE registration):
a) CHEQUES payable to ALBERTA CANCER FOUNDATION (Pigeon Lake Pedal)
b) CREDIT CARD Pay for your registration or make a donation on line by going to http://donate.albertacancer.ca/netcommunity/pigeonlakepedal
Credit card payment by phone (780) 432-8365 Toll free 1 866 412-4222 or fax (780) 432-8357.
3. Mail, fax or deliver the Registration form (*after ensuring payment by one of above methods) to:
Pigeon Lake Pedal c/o Michelle Ponich, Alberta Cancer Foundation,
11560 University Ave, Edmonton, AB, T6G 1Z2
4. Collect pledges - complete pledge forms make sure all information is collected for tax receipts.
100% of proceeds benefit patients and cancer research.
1 entry for prize draw for every $100 collected by July 4, 2009
Questions? Contact Michelle (780) 432-8365 e-mail michelle.ponich@cancerboard.ab.ca
www.pigeonlakepedal.com