subject_line
Partners For Progress Rider Registration
Client Information
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip Code
*
County (Lake, Cook, McHenry, Walworth)
*
Year Born
*
Ethnicity
Caucasian
African American/Black
Hispanic/Latino
Asian
Middle eastern
Pacific Islander
Native American/Alaskan
Other
Parent / Legal Guardian
If client is a minor there must be a parent/guardian indicated below.
If address is same as the rider it does not need to be re-entered.
First Name
Last Name
Address
City
State
Zip Code
Current Employer
Employer City
Second Parent / Legal Guardian
If address is same as the rider it does not need to be re-entered.
First Name
Last Name
Address
City
State
Zip Code
Current Employer
Employer City
Emergency Medical Information
Emergency Contact:
*
Emergency Contact Phone Number:
*
Preferred Medical Facility
Billing Information
Invoices are emailed two weeks prior to each session. Please provide email address for receipt.
*
Name of Contact for Billing Questions
*
Cell phone
*
If you would like your credit card charged for session fees when due. Provide your credit card information at the PFP office. An additional charge of .025 percent will added to each invoice to cover credit card processing fees.
I would like my credit card charged for session fees when due
*
Yes
No
Fundraising Options
Select one of the two choices below:
*
I agree to particpate in fundraising by selling raffle tickets for the Plop to raise $400 and contributing to the Hoe Down fundraiser. Session fees will be $48 a ride.
I choose not to particpate in the fundraising events and will be charged $60 a ride
Photo Release
I authorize the use and reproduction by Partners For Progress NFP and/or Pediatrics in Motion of any photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibits or for any other use for the benefit of the program.
*
I consent
I DO NOT consent
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