Gingerbread Chase Registration Form

JIRDC Gingerbread Chase Registration Form

December 2, 5:00 PM - 8:00 PM at J. Iverson Riddle Developmental Center
Join us rain or shine for this family-friendly event for all fitness levels. All proceeds are used to support individuals with intellectual and developmental disabilities at the J. Iverson Riddle Developmental Center.
- T-shirts not guaranteed after the cut off date.
- Parking will be identified by signage
Early Bird Registration cut off, November 16, 5:00 PM.

(Medals and t-shirts cannot be guaranteed after cut off)
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Add each participant you are registering below, including yourself. If you are only purchasing t-shirts, list each shirt and size on a new line.

Emergency Contact: Who can we contact if someone in your group has an emergency during the event?

First NameLast Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Payment for Registrants
prevnext( X )
Adult Registration ($25.00 plus $1 processing fee)
$26.00 Quantity



Child Registration ($20 plus $1 processing fee)
$21.00 Quantity



Late Registration ($30 plus $1 processing fee)
$31.00 Quantity



T-shirt only (make sure you indicated each shirt and size above)
$20.00 Quantity



Total

$0.00
Signature
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

JIRDC Gingerbread Chase Registration Form