Piece Ride for Autism Registration Form
Driver Name: _______________________ ______________________
_______
Last First
MI
Address: ______________________________________________________________
______________________________________________________________
Phone:
(_____) _____ - _______ Email Address: _________________________
I agree to hold harmless all rest areas, corporations, sponsors, organizers,
volunteers, and all other locations and persons
affiliated with Piece Ride for Autism.
Driver Signature: _____________________________________ Date:
____/____/2013
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Passenger
Name: _____________________ ____________________ _______
Last
First MI
Address: ______________________________________________________________
______________________________________________________________
Phone:
(_____) _____ - _______ Email Address: _________________________
I agree to hold harmless all rest areas, corporations, sponsors, organizers,
volunteers, and all other locations and persons
affiliated with Piece Ride for Autism.
Passenger Signature: _________________________________ Date:
____/____/2013
Pre register by mailing a completed form and check
for
entry fee made payable to Autism Support Daily to:
21 Bellevue Street Winooski, VT 05404