dash

Commuter Dash Registration & Triad Commute Challenge Pledge
RequiredRequired Question(s)

By registering for the Commuter Dash 5K you are pledging that you will try alternative transportation at least once by June 10, 2012! *You must be 16 or older to register and pledge.

 
Required 1.

Please provide us with the following information. (We will use this information to contact you if you win a prize.)


First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
City:
State/Province
(US/Canada):

Required 2.

Birthdate: (Please use this format xx-xx-xxxx)

 

50 characters left.
Required 3.

Gender:

Female
Male
Required 4.

Emergency Contact Name:

 

50 characters left.
Required 5.

Emergency Contact Phone: (xxx-xxx-xxxx)

 

50 characters left.
Required 6.

Home Zip Code

 

50 characters left.
Required 7.

Employer / School Name

 

50 characters left.
Required 8.

Employer / School Zip Code

 

50 characters left.
Required 9.

Which alternative(s) will you try?

 

Carpool
Vanpool
Ride The Bus
Bike
Walk
Telecommute
Required 10.

How do you currently get around? (check all that apply)

 

Drive Alone
Carpool
Vanpool
Ride The Bus
Bike
Walk
Telecommute
Required 11.

How did you hear about the Triad Commute Challenge? (check all that apply)

 

Employer/Co-worker
Friend/Family
Event/On-Site
Email
Internet
Media
12.

Code (For office use only)

 

 

50 characters left.