Highlight this form, print it and mail
"Ride for the Relay 2015"
September 5, 2015
"10th Anniversary"
Participant Application 2015
Starting Point: _________________ Ending Point: _______________
Name: ___________________________________________________
Corporation: ______________________________________________
Address: _________________________________________________
City/State/Zip: _____________________________________________
Telephone: ___________________ Alt: _________________________
eMail address: _____________________________________________
Corporate Sponsor: ( ) $660
Pin Sponsor: ( ) $330
Non-Rider Gold Sponsor: ( ) $132
Non-Rider Silver Sponsor: ( ) $66
Non-Rider Bronze Sponsor: ( ) $ 33
Rider Package: ( ) $132 ------ T-Shirt Size: S M L XL XXL XXXL
Passenger Package: ( ) $132 ------ T-Shirt Size: S M L XL XXL XXXL
Riders Package includes: T-Shirt, Patch, Pin, Cap, Windshield Decal,
5 Raffle Tickets, ATWG Plaque and first time ATWG Patch.
Passenger Package includes. T-Shirt, Patch, Pin, Cap, 10 Raffle Tickets,
ATWG Plaque and first time ATWG Patch.
Send all 2015 Participant Applications to:
Ride for the Relay 2015
C/O Rodger L. Fox
63 East Central Park Plaza
Jacksonville, Illinois 62650
Make all checks payable to Ride for the Relay or the American Cancer Society
Call 217-473-1525 if you have any questions.