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Employee Name
First Name


Last Name

Employee Email Address

Work Phone Number
- -

My round-trip bicycle commute trip is miles.

I have bicycled to work in the last 12 months

  Yes      No

I get to work most of the time by:

  Bicycle    Drive Alone   Carpool
  Transit   Vanpool   Walking

I hereby assume all risks inherent in any physical activity and release and hold harmless any event organizers and their employees of any and all claims and liabilities and am fit to participate in this event.

I pledge to bicycle to work at least 1 day during Bike to Work Week
May 17 - 21, 2004

  I accept   I do not accept


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For more information about SABA, please contact: saba@sacbike.org
Please send corrections and revisions to: saba@sacbike.org.