HARBOR HOUSE 400
RIDE FOR NEW BEGINNINGS
APPLICATION

Ride Option:
$75 for 5 Day Ride, July 9-13 $50 for 3 Day Ride, July 11-13 $25 for 1 Day Ride, July 13 Only

T-Shirt Type: Athletic Short Sleeved
T-Shirt Size: Small Medium Large XLarge XXLarge

Last Name First Name MI

Birth Date Employer Sex Male Female

Street Address

City State Zip

Telephone Numbers:
Home Phone Business Phone Cell Phone Email

Emergency Contact Emergency Contact Phone Number

Bicycle Make and Model Tire Size Valve Presta Shrader

In consideration of being accepted as a Harbor House 400 Ride for New Beginnings participant, I, the undersigned, intending to be legally bound, do hereby for myself, my heirs, executors, administrators or assigns, waive, release and forever discharge any and all rights and claims I may have against Harbor House, the officers, members, sponsors and any other persons connected with the Harbor House 400 Ride for New Beginnings, for any liability from any injury, illness or death sustained as a result of my participation in any activities associated with the Ride For New Beginnings.

If a rider, I warrant that I am at least 18 years of age, in good physical condition and will be trained sufficiently for a ride of this duration. I am competent to ride safely, and I agree to obey all traffic laws of the States in which I ride. I have no disabilities that will affect my ability to ride. My bicycle equipment is in good, safe working order. I agree to wear a CPSC-approved bicycle helmet while biking on the Ride For New Beginnings and on any of the official Harbor House 400 training rides.

I understand that I, as a 5-day or 3-day participant, am required to raise a minimum of $750 in pledges for Ocean's Harbor House Foundation. I understand that this waiver will be enforced under and interpreted by the laws of the State of New Jersey. I agree to allow the use of my photo and/or video for promotional purposes regarding Harbor House.

I Agree With The Above Statements I Disagree With The Above Statements

Date of Agreement

Please Note:

Fundraising is the critical component and purpose of the Ride for New Beginnings. Each participant, rider or support crew member, is required to raise a minimum of $750 in pledges.

Each rider is responsible to ensure that his/her bicycle is in good mechanical repair, and equipped with the proper safety equipment.

Riders must be at least 18 years of age.

Responses to the following questions will help evaluate potential participants and find additional sources of support.

1. Describe your cycling experience as related to the ride, i.e., average cycle distance/speed, experience, etc:

2. How did you hear about this ride?

3. Why do you want to participate in this ride?

4. Would you be willing to collect or speak at churches? Collect Speak

5. Do you belong to, or know of, any organizations that may be able to support our cause (e.g., churches, service clubs, unions)? If so, please list contacts and note where you are a member.

6. Does your employer make corporate donations or have a gift-matching program? If so, who is the company contact? Name Telephone Number

7. Can you submit a news release about the ride to your company newsletter? Yes No

8. Please list your other interests and hobbies:

9. Are you able to donate a vehicle and make it available the day prior to the ride? Yes No

10. Are you able to make available a bike rack for a SAG vehicle? Yes No
If yes, please provide type:

Please complete form completely before submitting. Please send non-refundable registration fee to: Ocean's Harbor House Foundation, Attn: RFNB, PO Box 1714, Toms River, New Jersey, 08754. Make all checks payable to "Ocean's Harbor House Foundation, Inc."