2019 Cycle Across Illinois - Participant Application. THE REGISTRATION FOR THE 2019 CYCLE ACROSS ILLINOIS IS FULL. IF YOU WISH TO COMPLETE THE FOR YOUR INFORMATION WILL BE SAVE AND YOU WILL BE NOTIFIED WHEN THE REGISTRATION IS OPEN FOR THE 2020 CYCLE ACROSS ILLINOIS.
Thanks for your interest in the 15th Annual Cycle Across Illinois benefiting the Illinois Chapter of Concerns of Police Survivors! Below you will see a series of questions, the answers to which are required for your application to be successfully entered into our system.

This application is required to be completed NO LATER THAN MARCH 31, 2019. Additionally, don't forget that we need your $175 non-refundable deposit no later than April 30, 2019. All money should be send to:

Concerns Of Police Survivors-Cycle Across Illinois
PO Box 4312
Wheaton, IL 60189

After answering the questions, don't forget to hit the "Submit" button at the bottom! You will receive a confirmation email after we receive your application.

Thanks and be safe!

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Are you registering as a Rider or as a Support Member? *
Required
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age (at the time of the ride) *
Your answer
Gender *
Required
Street Address *
Your answer
City of Residence *
Your answer
State of Residence *
Your answer
ZIP Code *
Your answer
Primary Email *
Your answer
Primary Phone # *
312-123-4567
Your answer
Cell Phone # *
312-123-4567
Your answer
Work Phone #
312-123-4567
Your answer
Rider Jersey Size
Rider jersey are a sport cut.
Captionless Image
Support Shirt Size
With arms down at sides, measure around the upper body, under arms and over the fullest part of the chest.
Captionless Image
Please list any medical conditions, take medications, or have any allergies we need to know about. *
Your answer
This years ride will be your __?__ time being part of Cycle Across Illinois as either a rider or support team? *
Emergency Contact Name *
Your answer
Emergency Contact's Relationship to Participant *
Your answer
Emergency Contact Phone # *
If more than one is needed, please separate by forward slash "/". 312-123-4567/312-765-4321
Your answer
Your Law Enforcement Agency (if applicable)
Your answer
Agency Phone #
Your answer
Supervisor's Name
Your answer
I agree to the below written liability waiver: *
In consideration of the foregoing, I for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against any of the sponsors, organizers, Police Departments, Illinois Concerns of Police Survivors for any and all claims of damages, demands or loss actions whatsoever which may arise as a result of my participation in this event. I understand and acknowledge that participating in this bicycling event may expose me to dangers from both known and unanticipated risks. I attest and verify that I am physically fit and have sufficiently trained for the event and my physical condition has been verified by a licensed medical doctor or if not, I waived said examination to participate. Further, I grant full permission to any and all of the foregoing to use my likeness for any legitimate purpose whatsoever. I have read, understand and agree to the above release and hereby place my digital signature to this form. Those riders under 18, must have the digital signature of their guardian.
I agree to the below written media release waiver: *
I hereby consent to and authorize the use and reproduction of any and all photographs, digital images, videotapes or recordings made of me for use by the Illinois Chapter of Concerns of Police Survivors, Inc., and its officers and agents while participating in the Cycle Across Illinois event July 17-21, 2019. I also give permission for the photographs, digital images, videotapes, or recordings to be used in their entirety and/or edited versions by the Illinois Chapter of Concerns of Police Survivors, Inc., including the use the of images on our websites, newsletters, and social media pages. Furthermore, permission is also given for the photographs, digital images, videotapes, or recordings to be used by the Illinois Chapter of Concerns of Police Survivors, Inc. at any time in the future without further clearance from me. I have read the foregoing release, authorization and agreement, before digitally signing below by completing this question, and warrant that I fully understand the contents thereof.
Tell us in your own words why you want to be part of this ride: *
(This is important to us as it will determine your eligibility to ride with the group if we near our rider number limits)
Your answer
Are you riding for any particular fallen officer? If so, who?
Your answer
Are you fundraising for this ride individually or as part of a team? *
Some people fundraise in groups - this is complicated for our organizers, so please pay attention to this question.
Required
If you're fundraising as part of a team, let us know your team name.
Your answer
If you're registering as a support team member and will be bringing a vehicle to the ride, please indicate the following.
What is the Make and Model of you Vehicle?
Your answer
Can you tow a trailer if needed?
Submit
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