2024 West of the 5th Poker Run Registration Form

1
Order Number
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Have you attended the West of the 5th Poker Run in the past?* This field is required.
YESNO
7
Indicate how many youth riders that will be participating with you.* This field is required.Youth Riders are ages 0-17. Youth riders may not hold a poker card however will have their own games and chance at prizes!
1 Youth Rider
2 Youth Riders
3 Youth Riders
4 Youth Riders
5 Youth Riders
No Youth Riders
8
West of the 5th Poker Run WaiverPlease read, download for your record. By completing this registration form you have acknowledged the waiver.
9
Waiver Signature* This field is required.Please complete the signature to verify that you understand registration and waiver
10
Poker Hand and Pre-Event * This field is required.Each rider over the age of 18 must provide a donation for their first hand. Optional are additional hands and pre- event. Please note you will receive and email confirmation and your credit card will show a payment to Mexi-can Property Solution. No refunds issued for poker hands. AGLC POKER RUN License #679537
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$20
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costCAD
First Poker Hand
One poker hand must be selected by each rider prior to the of a second hand. (Must be 18 or older to purchase) AGLC POKER RUN License #679537
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Additional Hands
Individuals can purchase as many additional hands as they wish to. They are not to be shared with other payers. (Must be 18 or older to purchase) AGLC POKER RUN License #679537
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Quantity
Subtotal:
Friday Feb 23, 2024 PRE EVENT!
Dinner and Dance - Social event - pick up your cards. Family Friendly Held at Lakedell Ag Society Hall
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Quantity
Subtotal:
Total cost
Payment Methods
Credit Card
First Name
Last Name
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
11
Event Details!Join the Facebook or Instagram page for all up to date information!
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