Evan’s Ride Registration Form Sunday, May 31, 2015 Form may be photocopied if necessary. Pledges can also be made online at www.evansride.ca Name (First & Last): ___________________________________________________________________________ Team/Family Name: __________________________ Address: _________________________________________________________________ City/Province: ________________________ Postal Code: _____________ Tel (W/H): ________________________________________________________________ Email: ________________________________________________________ PLEASE PRINT CLEARLY. WE CANNOT GUARANTEE A TAX RECEIPT WITH INCOMPLETE INFORMATION Cheques payable to Autism Community. Receipts will be issued for donations of $20 or more. Charitable number: 81448 2931 RR0001 Name Mailing Address, City, Postal Code Email Generous Donor 123 Main Street, Smithville, ON L0R 2A0 [email protected] $Pledge $20 Paid ✓ Amount Raised PLEASE READ CAREFULLY & SIGN BELOW WAIVER: in consideration of Autism Community o/a Evan’s Ride for Autism accepting my entry and that of my child(ren), by signing for myself and my child(ren), I hereby release Autism Community, event organizers, the Sheldrake family, JW Sheldrick Transport and all volunteers assisting in the event from liability and waive any and all claims for all damages whatsoever, including claims for negligence, which I or my child(ren) may have as a result of my and their participation. I acknowledge that I have read this release in its entirety, and that I understand and agree to be bound by its terms. I also consent to the use of personal information contained in this registration form for the purpose of soliciting my participation in future Autism Community events. I also consent to to the use of my and my child(ren)’s name, results and awards, photos, and audio and video recordings from this event in any form of promotional material for Autism Community o/a Evan’s Ride for Autism. Signature _____________________________________________________________________ Date: ______________________________________________ FOR PARTICIPANTS YOUNGER THAN 18 & FOR PARTICIPANTS’ WITH FAMILY MEMBERS UNDER 18 One parent’s/guardian’s signature can cover all of their children under 18 years. Anyone 18 years of age or older must have their own form. As a parent /legal guardian, I hereby give permission for the below-named to participate in this event for Autism Community on the basis of the conditions set forth in the above waiver. Signature _____________________________________________________________________ Date: ______________________________________________ Please list the names of all family members participating under the parent/guardian signature under the age of 18. ___________________________________ ____________________________________________ _________________________________________