Ady’s Racers Registration (Nick)

Parent Name*

First Name Last Name

Child's Name*

First Name Last Name

Total Siblings Participating*

Child's Name - Sibling 1*

First Name Last Name

Child's Name - Sibling 2*

First Name Last Name

Child's Name - Sibling 3*

First Name Last Name

Child's Name - Sibling 4*

First Name Last Name

Child's Name - Sibling 5*

First Name Last Name

Child's Name - Sibling 6*

First Name Last Name

Child's Name - Sibling 7*

First Name Last Name

Email Address*

Phone*

Address*

Street Address City State ZIP Code

Please share your story of your special needs child. Please let us know what special needs your child has. If there are siblings who are participating, please let us know the ages and height. Please let us know your favorite Bible verse for your child.*

Does your child use a wheelchair?*

Yes
No

I would like to attend and participate in the following activity(s):

Ride along racing program
Horseback riding
Pictures with Santa

Please note, you may select more then one, but only the ride along program has limited availability, therefore checking the box does not guarantee a spot for a racing.

Please submit a picture of your child and siblings.

Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 25 MB.

By submitting a picture, you are giving Ady's Army to use your story and/or image for marketing purposes.

Additional picture

Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 25 MB.

If you are NOT selected for the racing part of Ady's Racers, would you still like to attend the event?*

Yes
No

Please note!

You must be at least 5 years old to participate in the ride-along racing part of Ady's Racers. If your child is selected, you are giving Ady's Army permission to use your story and/or images to solicit donations for Ady's Army. Filling out the registration form and/or paying the deposit does not guarantee a spot.

Total

$0.00

Credit Card*

Card Details

Cardholder Name

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