DCCXIV - BTC Registration Form
Please complete the registration form below.
Name
*
First Name
Last Name
Email
*
example@example.com
Which BTC group are you a part of?
*
Break the Cycle - General Member
Break the Cycle - Northwest Rydas
Break the Cycle - Miami Gardens
Which DCC event will you be participating in?
99 mile ride - Jason Taylor Ride
54 mile ride - Zach Thomas
39 mile ride - Larry Csonka
13 mile ride - Dan Marino Ride
5K
What is your t-shirt size?
*
Please Select
Women's X-Small
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Men's XXXL
What is your cycling jersey size?
*
Please Select
Youth Small
Youth Medium
Youth Large
X-Small
Small
Medium
Large
XL
XXL
XXXL
XXXXL
What is your cycling shorts size?
*
Please Select
Youth Small
Youth Medium
Youth Large
X-Small
Small
Medium
Large
XL
XXL
XXXL
XXXXL
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
This will be my __ DCC!
*
1st
2nd
3rd
4th
Other
Are you a cancer survivor?
*
Yes
No
Gender
*
Male
Female
Prefer not to answer
Date of Birth
*
-
Month
-
Day
Year
Date
Ride Speed
*
Group A: 18-20 mph
Group B: 15-18 mph
Group C: 12-15 mph
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number
*
Please enter a valid phone number.
If registering a minor... Parent's Name
First Name
Last Name
Parent's Date of Birth
-
Month
-
Day
Year
Date
Each participant on Team BTC is responsible for fundraising for life-saving cancer research. 99 mile ride - $1,000; 54 mile ride - $750; 39 mile ride - $500; 13 mile ride - $500; 5K - $500. All donations will go to the UM-Sylvester Comprehensive Cancer Center. Are you willing to make every effort to fundraise?
*
Yes
No
Did someone invite you to join Team BTC?
Yes
No
If you answered yes to the previous question, please type that person’s name below.
Submit
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