1st Annual Horse-A-Thon Fundraiser
Pre-Registration for April 2011
BHR Event General Info and Agenda

I am interested in learning about this event

Individual Rider Information (Please complete form for each individual rider)
     (for printable version click here)

Club Name
* First Name
* Last Name
Age	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110+
* City
* State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
* Zip
Gender	Male Female
Contact information: * Phone  format:(888) 555-1212
Alternate Phone format:(888) 555-1212
* Email Address
Would you like to receive the Black Heritage Riders Newsletter? Yes No
May we list your name and state listed on our page of those who will be present?  Yes No
Are you interested in serving on the planning committee for your state? Yes No

* Required field

City and State information will be used to map out route and participant interest.

If your club is interested in riding a leg of the journey, please call us at 1-877-88-GOBHR(1-877-884-6247) or contact Miles Dean.