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HELPING HANDS POKER RUN REGISTRATION
Helping Hands Poker Run Registration
dev@spikesalesnow.com
2024-03-03T23:23:15+00:00
Discover the Ultimate Off-Road Adventure at USARC’s Helping Hands Poker Run
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Choose the Perfect Option Tailored for You!
DRIVE MY VEHICLE
MAKE SELECTION
DESERT CRUISE COURSE – $60.00
RUGGED RIDE COURSE – $100.00
BOTH COURSES – $130.00
Total
*
$0.00
TAKE A SIDE x SIDE TOUR
MAKE SELECTION
1 Seat on SIDE x SIDE Tour – $80.00
2 Seats on SIDE x SIDE Tour – $160.00
3 Seats on SIDE x SIDE Tour – $240.00
TAKE A JEEP TOUR
MAKE SELECTION
1 Seat on JEEP Tour – $80.00
2 Seats on JEEP Tour – $160.00
3 Seats on JEEP Tour – $240.00
4 Seats on JEEP Tour – $320.00
Next
Driver
Driver Name
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First
Last
Email
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Vehicle Type
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MAKE SELECTION
ATV | Dirt Bike
SIDE x SIDE
4×4 Jeep | 4×4 Truck | 4×4 SUV
Mobile Phone
*
Shirt Size
*
MAKE SELECTION
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Date of Birth
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Driver's Emergency Contact Name
*
Emergency Contact's Mobile Phone
*
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Rider #1
Rider #1 Name
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First
Last
Phone
Email
Date of Birth
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Shirt Size
*
MAKE SELECTION
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Rider's Disability
*
MAKE SELECTION
N/A
Acquired Brain Injury
Amputee
Cancer
Cerebral Palsy
Developmental Delay
Hearing Impaired
Muscular Dystrophy
Multiple Sclerosis
Post Polio
Spina Bifida
Spinal Cord Injury
Visual Impairment
Other
Please provide further details about rider's disability.
Emergency contact person.
Rider's Emergency Contact Name
*
This emergency contact applies to all riders.
*
Yes
No
Emergency Contact's Mobile Phone
*
Additional Emergency Contacts
Provide the name and mobile phone numbers for any additional emergency contacts.
Next
Rider #2
Rider #2 Name
First
Last
Phone
Email
Date of Birth
*
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Shirt Size
*
MAKE SELECTION
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Rider's Disability
*
MAKE SELECTION
N/A
Acquired Brain Injury
Amputee
Cancer
Cerebral Palsy
Developmental Delay
Hearing Impaired
Muscular Dystrophy
Multiple Sclerosis
Post Polio
Spina Bifida
Spinal Cord Injury
Visual Impairment
Other
Please provide further details about rider's disability.
Previous
Next
Rider #3
Rider #3 Name
*
First
Last
Phone
Email
Date of Birth
*
MM
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1921
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Shirt Size
*
MAKE SELECTION
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Rider's Disability
*
MAKE SELECTION
N/A
Acquired Brain Injury
Amputee
Cancer
Cerebral Palsy
Developmental Delay
Hearing Impaired
Muscular Dystrophy
Multiple Sclerosis
Post Polio
Spina Bifida
Spinal Cord Injury
Visual Impairment
Other
Please provide further details about rider's disability.
Previous
Next
Rider #4
Rider #4 Name
*
First
Last
Phone
Email
Date of Birth
*
MM
1
2
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4
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DD
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1933
1932
1931
1930
1929
1928
1927
1926
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1924
1923
1922
1921
1920
Shirt Size
*
MAKE SELECTION
Men's Small
Men's Medium
Men's Large
Men's XL
Men's XXL
Women's Small
Women's Medium
Women's Large
Women's XL
Women's XXL
Rider's Disability
*
MAKE SELECTION
N/A
Acquired Brain Injury
Amputee
Cancer
Cerebral Palsy
Developmental Delay
Hearing Impaired
Muscular Dystrophy
Multiple Sclerosis
Post Polio
Spina Bifida
Spinal Cord Injury
Visual Impairment
Other
Please provide further details about rider's disability.
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Name As It Appears On Credit Card
*
First
Last
Credit Card Details
*
Please complete all payment details. A receipt will be sent to the purchaser’s email provided above.
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Would you be willing to make an extra donation to help USARC with our outdoor recreational programs?
Extra Donation to USARC – $10.00
Extra Donation to USARC – $25.00
Extra Donation to USARC – $50.00
Extra Donation to USARC – $100.00
Extra Donation to USARC – $250.00
Extra Donation to USARC – $500.00
Extra Donation to USARC – $1,000.00
Extra Donation to USARC – $2,500.00
Extra Donation to USARC – $5,000.00
NO EXTRA DONATION 😞 – $0.00
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