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Peloton Rider Application
Please complete the form to apply for the 2016 Wellspring Peloton Challenge.
If you have any questions, please contact Susan Chung at
susan@wellspring.ca
or call 416-961-1928 ext. 238.
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Last Name
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Your answer
Given Names
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Your answer
Address Line 1
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Your answer
Address Line 2
Your answer
City and Province
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Your answer
Cell Phone Number
*
Your answer
Home phone number
Your answer
Email Address
*
Your answer
Principal Occupation
Your answer
Date of Birth
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MM
/
DD
/
YYYY
Sex
*
Male
Female
How did you hear about the Wellspring Ride for Cancer Support, Peloton Challenge? (select all that apply):
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Family/Friend
Website or AD
Poster or Brochure
Wellspring Literature
Other:
Why are you interested in becoming a rider for the 2016 Wellspring Ride for Cancer Support, Peloton Challenge?
*
Your answer
Endurance Events
Please describe your comfort level with endurance events
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Not at all comfortable
1
2
3
4
5
Extremely comfortable
Please describe your experience with endurance cycling:
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Your answer
Cycling Experience
Please rate your comfort level with cycling:
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Not at all comfortable
1
2
3
4
5
Extremely comfortable
Please describe your cycling background:
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Your answer
How many kilometers a year do you cycle?
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Your answer
What is the longest distance you have cycled in a single day?
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Your answer
Fundraising
Please describe your comfort level with fundraising:
*
Not at all comfortable
1
2
3
4
5
Extremely comfortable
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