Adult Bicycle Maintenance 101 Form Adult Bicycle Maintenance 101 Form Participant InfoParticipant Name(Required) First Last Participant Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Birthday(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Youth InfoAre you signing up a child between the ages of 14 and 17 for this? If you answer yes, please fill out the following section:(Required)YesNoYouth Name First Last Youth BirthdayMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact InfoCell Phone Number(Required)Email(Required) Are there specific issues with your bicycle that you'd like to learn more about? Discount Eligibility InformationThis section will be used to determine if a discounted rate will be applied to your registration if you are interested in being considered for a discounted rate.What is your current household income? Is the above income yearly, monthly, or weekly?YearlyMonthlyWeeklyHow many people are in this household that are supported by this income? Emergency Contact InformationName:(Required) First Last Phone:(Required)Relationship:(Required) Δ
