2017 ANNUAL CONNECTION TOUR REGISTRATION FORM
Please fill out this form in its entirety.

If you have any questions contact me using the email address below.

We look forward to seeing you in Paso!

Fred Roth
fredr@cyclingconnection.org

Email address
CYCLING CONNECTION MEMBERSHIP
For insurance purposes you must be a current member of Cycling Connection of Rancho Cucamonga. If you are not please visit the following page (opens in a new tab/window) to complete your online membership

http://cyclingconnection.org/Membership.html

Current Cycling Connection Member?
YOUR PERSONAL INFORMATION
First Name
Your answer
Last Name
Your answer
Mailing Address and Zip Code
Your answer
Contact Phone Number
Preferably a Cell Phone
Your answer
Emergency Contact Phone
Preferably a Cell Phone
Your answer
Emergency Contact Name and Relationship
In the event of an Emergency please list any information you would like the responders to know (health conditions, allergies, medications, etc.)
Your answer
Medical Provider Name
Do NOT Provide Medical ID
Your answer
Medical Provider Phone
Your answer
ANNUAL CONNECTION TOUR OPTIONS
Select your accommodations
Car Pool / Pick up Options
Special Food needs?
List any special food needs you have
Your answer
T-Shirt Size
Your answer
ANNUAL CONNECTION TOUR FEES
Campers (Including RV on site) $170*
Off-site accommodations $110*
(an event T Shirt is included in the registration fees)

If you are paying by check please make payable to Cycling Connection and send to :
Fred Roth
6276 Mayberry Ave,
Rancho Cucamonga, CA 91737

*a small fee will be added for online payment

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