2024 DCC Registration Form

DCCXIV - BTC Registration Form

Please complete the registration form below.
Name*

First NameLast Name
Email*
example@example.com
Which BTC group are you a part of?*

Break the Cycle - General MemberBreak the Cycle - Northwest RydasBreak the Cycle - Miami Gardens
Which DCC event will you be participating in?

99 mile ride - Jason Taylor Ride54 mile ride - Zach Thomas39 mile ride - Larry Csonka13 mile ride - Dan Marino Ride5K
What is your t-shirt size?*
What is your cycling jersey size?*
What is your cycling shorts size?*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
This will be my __ DCC!*

1st2nd3rd4thOther
Are you a cancer survivor?*

YesNo
Gender*

MaleFemalePrefer not to answer
Date of Birth*

MonthDayYear
Date
Ride Speed*

Group A: 18-20 mphGroup B: 15-18 mphGroup C: 12-15 mph
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*
Please enter a valid phone number.
If registering a minor... Parent's Name

First NameLast Name
Parent's Date of Birth

MonthDayYear
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?*

YesNo
Did someone invite you to join Team BTC?

YesNo
If you answered yes to the previous question, please type that person’s name below.
Should be Empty:

DCCXIV - BTC Registration Form