Registration Form

First Name*

Last Name*

Address*

City*

State*

Zip*

Home Phone

Area CodePhone Number

Emergency Contact Name(if parent or guardian is not avaliable)*

Emergency Number*

Area CodePhone Number

Emergency Number #2

Area CodePhone Number

Birth Date*

MonthDayYear

CURRENT AGE*

Parent/Legal Guardian*

Cell Phone

Area CodePhone Number

Parent /Legal Guardian 2

Cell Phone 2

Area CodePhone Number

Email:

Any physical, mental or other condition that would require special attention or medication while in our care?*

Electronic signature, please initial*

Can we use pictures and videos of your child on our social media pages?

YesNo

I further acknowledge and understand that Pedal 4 Peace have established rules and regulations pertaining to conduct, behavior and activities of all participants by which my minor and I agree to abide, and that Minor and I will be responsible for his/her/my failure to abide by those rules and regulations. Minor and I have received, read and understand the rules. Minor and I understand that violation of the rules can result in dismissal from program.

Pedal 4 Peace USA, Inc. is an outdoor physical ativity program. Parents or guardians understand that Pedal 4 Peace USA, Inc is not responsible for any injuries occured during program activities. Youth will articipate in Biking and Equine activities at there own discretion.

By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize Pedal 4 Peace USA, Inc to use my camper's picture, testimony, and video in any promotional material(web,print,or media) I may recieve any e-mails from the camp.

Signature*

Experience Modules

Experience BMXExperience MTBExperience HorsemanshipExperience Wilderness Survival

Electronic signature, please initial*

My Products

(Paypal or Credit Card)Registration Fee+Processing $120.00

Each module cost $40. If you purchase all 4 together save $40 and pay $125.00

Pay Cash $120 (No Processing Fee)$ Free

Individual Modules$40.00

Choose: Experience MTB Experience BMX Experience Horsemanship Experience Wilderness Survival

Enter coupon

Total $0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

PEDAL 4 PEACE Program Module REGISTRATION

CHILD'S NAME AND ADDRESS

Parent or Legal Guardian Information

Email Confirmation

Other Information

Release INFORMATION