Wheels of Love 2022 - Registration Form for Road Plus Route

Registration fees:

Early Registration until September 1: $1,200/3,850NIS
Late Registration September 2 – October 31: $1,500/4,820 NIS

ALYN Hospital will spend $2000 total per rider for the four-day period. In the interest of minimizing the financial impact on ALYN, please consider making a personal donation to cover the difference between your $1200 registration fee and the $2000 cost to the hospital. Donate here.

Questions? Email us at specialprojects@alyn.org.

basic info

riding preferences

Fundraising

secure pay

Please tell us about yourself

X*First Name (English)

X*Last Name (English)

XFirst Name (Hebrew)

XLast Name (Hebrew)

X*Phone

X*Language Preference

X*E-mail of participant

X*Date of Birth

X*Gender

MaleFemalePrefer not to answer

XPassport Number (non-Israelis)

XTeudat Zehut (for Israelis)

X*Address line 1

XAddress line 2

X*City

XState

X*Country

X*Postal Code

X*By checking this box, you acknowledge being added to our mailing list for important ride updates.

Please tell us your preferences for the ride

XSpecial Diet

X*Jersey Size

X*Emergency Contact Name

X*Emergency Contact Mobile Phone

X*How did you hear about the ride?

XTeam

Registration includes accommodation in a triple room.
Upgrade is available to a single room ($750) or share a double ($250 each person.)

XHotel Upgrade (3 nights)

XHotel Room Night Before Ride

XRoomate Preference #1

XRoomate Preference #2

XI am not bringing my own bike and will need to rent one

You need to approve the previous step to continue

FUNDRAISING

To help you fundraise, we will create a personal fundraiser page for you. Would you like to add a personal message? (250 character maximum)

XAdd Your Personal Message

The minimum fundraising requirement for Road Plus is $5,000

X*If I have not met the requirements by ride check-in, I will give a credit card number as a security deposit. If I do not meet the requirements by December 31, 2022, my credit card will be charged to cover the balance.

X*I have read and agree to the Cancelation Policy

2022 Wheels of Love Cancelation policy

AGREEMENTS AND CERTIFICATIONS

X*I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.

I have checked the above declaration, but I want ALYN to know that I have the following medical conditions and take the following prescription medications:

XMedications

XMedical condition

I AM AFFIRMING THAT I HAVE READ AND UNDERSTAND THE WHEELS OF LOVE 2022 WAIVER AND RELEASE. I UNDERSTAND THAT THE PARTICIPANT IS GIVING UP SUBSTANTIAL RIGHTS, INCLUDING THE RIGHT TO SUE. THIS IS A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. BY CLICKING THE BOX, I INDICATE MY ACCEPTANCE OF THIS WAIVER AND RELEASE.

X*I AGREE TO WAIVER AND RELEASE

You need to approve the previous step to continue

Currency

Registration Fee: 1,200

Total Payment: 1,200

Approve and Pay

To pay in a different currency, please email us at specialprojects@alyn.org

Thank you for your registration.

Thank you for registering for the the ALYN Wheels of Love Ride. Your registration has been received and will be processed shortly. Since you selected the call-in payment option, please call one of the following numbers and make your payment within one week to confirm your registration:

US and Canada: 1-212-869-8085

Israel: 02-649-4235 or 02-649-4216