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Dice Run Online Registration Form (Driver & Rider)

Be sure to pay online at the link that will be provided
after you submit your registration information.

Driver's Name (last, first)*
Number and Street*
City, Village or Town*
State or Province*
Zip or Post Code*
Phone Number* (example 7164841212)
Email Address*
Gender (M or F)*
Shirt Size (youth or adult)

Injury Waiver I assume all risks associated with participating in this event, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release The Resource Center, TRC Foundation, Laurel Run organizers, sponsors, and volunteers and their employees, agents and successors from all claims or liabilities of any kind arising out of my participation in this event. I further grant permission to any or all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose. I AGREE* NOTE: Thanks for supporting people with disabilities by participating in Dice Run! $5 of your entry fee will be directed to our annual membership campaign, and as a member you are entitled to discounts at dozens of area businesses. If you do NOT want to be a member of TRC, check this box:

Rider's Name (last, first)*
Number and Street*
City, Village or Town*
State or Province*
Zip or Post Code*
Phone Number* (example 7164841212)
Email Address*
Gender (M or F)*
Shirt Size (youth or adult)

Injury Waiver I assume all risks associated with participating in this event, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release The Resource Center, TRC Foundation, Laurel Run organizers, sponsors, and volunteers and their employees, agents and successors from all claims or liabilities of any kind arising out of my participation in this event. I further grant permission to any or all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose. I AGREE* NOTE: Thanks for supporting people with disabilities by participating in Dice Run! $5 of your entry fee will be directed to our annual membership campaign, and as a member you are entitled to discounts at dozens of area businesses. If you do NOT want to be a member of TRC, check this box: