Rider Registration

Saturday, September 24, 2011

Trentadue Winery, Sonoma County CA

Rider Registration: Registration is $35 until July 1, and then $50 until we close on September 21.  Space is limited.

For your information, this is a multi-step process.  You will need to fill out this page, and then complete your Registration payment.  If you do not complete both steps, your registration has not been completed.

To register as a rider, please fill out this form.  *required fields
Rider's Name*
First Name
 Middle Name
 Last Name
IMPORTANT: If you are riding a tandem and you are the captain, please register as a VOLUNTEER. Then have the stoker register as the fundraising rider. If you have any questions, please call Moana at 510-849-4663 x1307 or email moana@borp.org before continuing with your registration.
Email*
Enter Email Again*
Phone*
   ext:
Don't forget your area code
Cell Phone
So we can contact you during The Revolution. Please include area code.
Address Line 1*
Address Line 2
City*
State*
     Outside USA: 
Zip*
Country
Select a team:
IMPORTANT: Check the pulldown to see if your team is already on the list. If it is not, you want to start a team, and your team has not been created, you must request that your team be created before you register. To create a team, click HERE.
Gender
Male   Female
Birthdate
 /   / 
Rider Information
Riders, tell us about your bike *
I'll ride my standard bike
I'll ride my handcycle
I'll ride my Foot Trike
I'll ride my tandem
I'll ride my unicycle
I'll ride a BORP handcycle
I'll ride a BORP foot trike
I'll ride a BORP Tandem

Which route do you plan to ride? *
 
10 Miles/Trail Ride, 25 Miles, 50 Miles, 65 Miles (100K)
If you are riding a handcycle, trike or tandem, and have one, who is your out-rider or tandem captain?

Please have your out-rider or tandem captain fill out a volunteer registration form and include your name as their partner.  If you need an out-rider or tandem captain, please email greg@borp.org .
What is your fundraising goal? *
(The more money you raise, the more prizes you earn!)		 $350 (required minimum): Festival+T-Shirt+Swag Bag
$750: Event Jersey+T-Shirt+Swag Bag
$2,500: 1 Extra Festival Ticket+Event Jersey+Festival+T-Shirt
       +Swag Bag
$5,000: Deluxe Cycling Accessory Pack + 1 Extra Festival Ticket
       +Event Jersey+Festival+T-Shirt+Swag Bag
$7,500: $100 REI Gift Certificate+Deluxe Cycling Accessory Pack
      +1 Extra Festival Ticket+Event Jersey+Festival+T-Shirt+Swag Bag
$10,000: Custom Bike+Deluxe Cycling Accessory Pack
     +1 Extra Festival Ticket+Event Jersey+Festival+T-Shirt+Swag Bag
$150: (for youth under 18 yrs only) Festival+T-Shirt+Swag Bag
Does your employer have a matching gift program?
Yes
No

If yes, please contact your employer for a matching funds application and forward it to BORP.
Who is your employer?
For matching funds purposes only.
Do you require a vegetarian meal? Yes I require a vegetarian meal
No I do not require a vegetarian meal
Revolution 2011 Cycling Jersey: Riders who meet fundraising incentives may earn a free cycling jersey*. If you plan to earn a prized jersey, please tell us your jersey size.

*Please choose appropriate fundraising level above.
What style jersey do you wear?
 
 (Women's, Men's Club or Men's Racing)
What is your cycling jersey size?
 
(XS, S, M, L, XL, XXL*, XXXL* - *Men's Only)
What is your T-Shirt size? *
 
(Women's S, M, L, XL Men's S, M, L, XL, XXL)
Emergency Contact Info
Who should we contact in case of an emergency? *
How is this person related to you? *

(Mother, Father, friend, co-worker)
Emergency Contact Phone Number *

(Please include the area code)
Any other comments for the BORP Revolution Staff? 
      

Top of Form
RELEASE OF LIABILITY - READ BEFORE SIGNING

In consideration of being allowed to participate in any way in the Bay Area Outreach and Recreation Program (BORP), its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:   

1.    The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2.    I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3.    I willingly agree to comply with the stated and customary terms and conditions for participation.  If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately: and,

4.    I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Bay Area Outreach & Recreation Program (BORP), their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.


FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE
(UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

Type your full name here if you are in agreement with the liability waiver:


MEDIA RELEASE

I hearby authorize and give my full consent to BORP to copyright and/or publish any and all photographs, videotapes, and/or film in which I appear while attending BORP events/activities. I further agree that BORP may transfer, or cause to be used these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations.
FUNDRAISING MINIMUM & AUTHORIZATION TO CHARGE CREDIT CARD - READ BEFORE SIGNING

I understand that The Revolution is the most important fundraising event for BORP, and that I must raise a minimum amount for BORP in order to participate.

The following minimums include my non-refundable registration fee:

For Adult riders over the age of 18, the minimum amount to be raised is $350.

For Youth riders ages 8 - 18, the minimum amount to be raised is $150.

If by September 24, 2011 (the day of The Revolution) I have not raised the minimum amount, I authorize Bay Area Outreach & Recreation Program (BORP), to charge me for the difference between what I have raised and the minimum amount required to participate.  If I have not raised the minimum by September 24, 2011, I will bring with me to the Revolution a credit card, check, or cash in order to cover the difference and make a payment to reach the fundraising minimum.

Type your full name here if you are in agreement with the fundraising minimum (required):


Type the number below into the box below (spam prevention):
   8923 -->Type that number here--> Bottom of Form
Would you like to be on the BORP eNewsletter list?

Please verify that all information above is correct before you click below.

1. Pay by logging into your PayPal account

OR

2. Pay without a PayPal account
 • Note that you do NOT need a PayPal account to pay with a credit card. Simply enter your credit card info and your contact info, and payment should go through.

OR

3. Payment by Check
  Please note that your registration status will remain as "pending" until we receive your payment. If you wish to pay by check, please make your check payable to BORP and mail to:
   BORP: Revolution Ride
   Attn: Moana Newman
   3075 Adeline Street, Suite 155
   Berkeley, CA 94703-2545