Alyssa's Ride Registration Form
Ride Date:--------April 24, 2010 Location: Euharlee Baptist Church 85 Covered Bridge Road Euharlee, Ga. 30120 Registration Starts: 8:00am.
Kickstand up 10:00am
Drivers Name:___________________________________________ Address:________________________________________________ State:_________________________Zip Code__________________ E-mail__________________________________________________ Shirt Size: s M
L XL
XXL Qty______ Dirver Donation of $35.00 Includes on Tee Shirt. Passenger Donation of $5.00 ( Does not include Tee Shirt )
Release Info: You are participating in this ride of your own free will and will not hold anyone accountable
for any accidents, loss or damage caused before, during or after this ride which includes but not limited to Euharlee
Baptist Church, City of Euharlee, GA. and Alyssa's Ride Foundation any of their employees, or volunteers,or any other
entity associated with this event. By signing below you understand and agree to this release form. Driver
Signature._________________________________________________ Passenger Signature.____________________________________________ By
Singing up early you can save $5.00 on the Drivers Registration. Early Registration must be in no later than April 20,
2010
Payment Type: Check:_________. Please make check payable to ALYSSA's Ride Foundation. Mail to: Alyss's
Ride Foundation P.O. Box 61 Taylorsville, Ga. 30178 Credit Card______ Type, M/C or Visa
( Please cirule one ) Name on Card _________________________________________________________________________ Address______________________________________________
State___________ Zip______________ Account #____________-______________-_______________-_______________ Expiration
Date________Month____________Year_____________ CVC#______________( 3-Diget on Back of Card ) Amount approved
to be deducted from your account $______________ Sign_______________________________________Date___________________ Please
mail Signed Registration form along with payment to: Alussa's Ride Foundation P.O. Box 61, Taylorsville,
GA. 30178
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