* 1. First Name

* 2. Last Name

* 3. Email

* 4. JDRF Chapter (if you do not know your JDRF Chapter, please say "I don't know")

* 5. City

* 6. State

* 7. Zip Code

* 8. Phone

* 9. Package

* 10. Have you participated in a JDRF Ride in the past?

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