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? Which class are you signing up for?(Required)Friday, April 7thSaturday, April 15thDiscount 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 the gross household income? (Gross income is your salary and earnings before taxes) | If you can only answer for one of the boxes please answer N/A in the other box. Annual Monthly How many people are in this household that are supported by this income? Emergency Contact InformationName:(Required) First Last Phone:(Required)Relationship:(Required) Δ