Bike to Work Day -- Sept 13, 2017
THANK YOU FOR YOUR INTEREST IN THIS YEAR'S BIKE TO WORK DAY.
PLEASE FILL OUT THE FORM COMPLETELY.
THE FIRST 200 PARTICIPANTS TO ENTER WILL RECEIVE A SPECIALIZED WATER BOTTLE.
First Name
Your answer
Last Name
Your answer
E-mail Address
Your answer
Phone Number
Your answer
Employer/Business Name (If a school please write the district you are employed by)
Your answer
What is the size of the business where you are employed?
How many miles do you travel (one way) from your home to work?
Your answer
On work days other than "Bike To Work Day," which ONE mode of transportation are you most likely to use for your commute to work?
How old are you?
How likely are you to continue biking to work in the future?
Highly Unlikely
Very Likely
Please check the box below indicating that you are aware of the dangers of an aerobic fitness event and that you have fully prepared for its rigors. Additionally, you release any sponsors of legal liability associated with the event and have independently obtained insurance for this event. By checking the box, you also grant permission to the Bear River Health Department to use your photograph for any promotional or educational purpose in any and all media without limit or reservation. Please note: All information provided will not be shared to other agencies or groups and will only be used for funding purposes.
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