Cycling Registration Form

REGISTRATION FORM

Location of city of leg you will ride______________________

Name:___________________________________________________

Address:_________________________________________________

City/State/Zip:______________________________________________

Phone/day:_______________________eve:_____________________

Email:___________________________________________________

Age:______________Sex: Male______Female_____

A beautifully designed commemorative patch
will be presented by Cookie to each rider

Participating as: _____an Individual _____a team

Name of Team:____________________________________________

Captain of Team: __________________________________________
Send team members with above information
along with registration form & fees

Company name: (Optional)__________________________

Entry fee: $15.00 individual
$12.00 per team member (minimum per team - 3)

Make checks payable to: New Life Mobility Assistance Dogs

Send registration form along with payment to:

Wildcat Ridge Riders
1255 Wildcat Ridge
Deep Gap, NC 28618

* Join Cookie or other rescued dogs in a leg in your area of:

"CYCLING THE CAROLINAS FOR NEW LIFE"

* Organize a Team to ride in a leg of the cycling event

* Join others in the COOKIE CHALLENGE at your local school
Call Dr. Jim Taylor at 828-264-0054 for more information

* Help NLMAD by seeking donations if you are unable to cycle.

* Visit Cookie & other dogs saved from shelters by Karen
to assist persons with disabilities at: www.nlmad.org

* For more information on a cycling leg in your area go to:

Also for info you can email/call

828-264-0054