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For additional information, please email us at
chickenjoesrideforkids@verizon.net
 
 
Registration Form
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Address:  
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Employer:  
Occupation:  
Gender: Male          Female  
Date of Birth: Month: Day: Year:  
Emergency Contact Number:  
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For additional information, please email us at:
chickenjoesrideforkids@verizon.net
 
 
 
 
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