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Please fill out the applicable fields below and enter all credit card information to pay online.
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Read and Verify
In consideration of the acceptance of my entry and other considerations, I for myself, my personal representative and other assigns, do hereby release and discharge the Keller Wellcare Center, Helen Keller Hospital, the Helen Keller Festival, the City of Tuscumbia and all participating sponsors from all claims rising or growing out of my participation in the Bike Ride. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event. I agree to wear a helmet and the appropriate safety equipment during the entire ride. |
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Name
Name of Participant |
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Address |
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City, State, Zip
Please include your city, state, and zip. |
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Phone Number |
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Gender |
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Age
Please enter your age on 6/23/17 |
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Birthdate
Please enter your date of birth. |
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Parent's Verification (if under of the age of 18)
Enter your name to verify that your child has permission to participate. |
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T-Shirt Size
If you would like a T-Shirt please select the size. |
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Please check one: |
5 Mile Family Ride 23 Mile Ride |
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Credit Card Type
Please select a card type. |
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Credit Card Number
Please enter your 16 digit credit card number. |
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3 Digit Code
Please enter your credit card's 3 digit security code |
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Credit Card Expiration Date
Please enter the expiration date.
Example 00/00 |
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