Event Registration

First Name: Last Name: Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix Email: Day Phone: Date of Birth (mm/dd/yyyy): Ethnicity/Race African American / Black American Indian / Alaskan Native Asian Caucasian / White European American Hispanic / Latino Pacific Islander Other What best describes your gender? Female Male Non-binary Prefer to Not to Answer Prefer to Self Describe Self describe gender Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender and/or Queer (LGBTQ+) community? Yes No Prefer Not to Answer What is your involvement with Dare2tri? (Check all that apply) Do you have a disability? Primary disability: Amputee/Limb Difference - Lower Limb(s) Amputee/Limb Difference - Upper Limb(s) Blind/Visually Impaired Cerebral Palsy Muscular Dystrophy Multiple Sclerosis Spina Bifida Spinal Cord Injury Stroke/TBI PTSD Other Physical Disability None Please indicate any other disabilities (check all that apply): Have you ever served in the armed forces? Yes No Branch of Service Not Applicable Army Air Force Navy Marine Corps Coast Guard National Guard Number of Participants: If you have a coupon, please enter code here (case-sensitive):