Form

SIGN UP for Harrisonburg Bike to Work Day 2011! Signing up makes you and your workplace eligible for PRIZES! (Signing up also helps us keep track of how we're doing, so: THANK YOU!)
Name (or nickname if you prefer)*
E-mail address (So we can contact you if you win a prize. We promise not to sell your email to spammers.)*
Phone number (if you consider this a good way for us to reach you.)
Workplace (We keep track of each workplace so we can award prizes and provide support.)*
Approximate Commute Distance (round trip)
I am interested in being the contact person for my place of work

Yes No Maybe
Bike Commuting Practices

I have never biked to work I have occasionally biked to work I sometimes bike to work I regularly bike to work
I would like help planning my route and/or other bike commuting logistics

Yes No
How did you hear about Hburg Bike2Work Day?
Questions or Comments
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SIGN UP for Harrisonburg Bike to Work Day 2011! Signing up makes you and your workplace eligible for PRIZES! (Signing up also helps us keep track of how we're doing, so: THANK YOU!)