BIKE MS: ESCAPE TO THE LAKE /// 2015 REGISTRATION /// JUNE 13 & 14
P L E A S E PR I N T C L EA R Y A N D B R I N G C O M P L E T E D F O R M & P A Y M E N T , T H A N K Y O U
Name: _____________________________________________________________________________
E-mail: ____________________________________________________________________________
Anniversary
30th
Address: ___________________________________________________________________________
City: _________________________________________State: __________ Zip: _________________
Phone:(______) _______________________
Sex: M F
Escape to
the Lake
Date of Birth (mm/dd/yy): ______________________
Riders must be at least 12 years old by 6/6/14
Team Name: ______________________________________ Team Captain: _____________________________________
FUNDRAISING GOAL: $______________________ (The minimum is $300, and is due by 6/13/2015)
Please tell us your connection to MS: ∑ I have MS ∑ Spouse of a person w/ MS ∑ Sibling of a person w/ MS
∑ Child of a person w/ MS
∑ Parent of a person w/ MS ∑ I have a friend or co-worker with MS
2015 will be my____________ year riding.
T-Shirt Size: S M L XL XXL
New for 2015***I will riding:
∑ Saturday Only
or
∑ Saturday and Sunday
Please select your SATURDAY ONLY route:
∑ 65 Miles
∑ 78 Miles
∑ 100 Miles (Century Route)
Will you be taking the National MS Society bus back to the start
location on Saturday, June 13? ∑ Yes or ∑ No
If you are using the transportation back to Moraine State Park
(Start Line) on SATURDAY and not riding on Sunday
transportation will happen in two trips.
∑ 4 pm or ∑ 7:30 pm departure time from Allegheny College
I am riding Saturday and Sunday, I will be taking the bus back to
the start location on Sunday? ∑ Yes or ∑ No
Lodging Options: (please select)
Registration for this Bike MS event does NOT include lodging. Please
visit the Accommodations page for more instructions on how to make your
reservation. For all participants staying on campus, a meal pass will be
included in the housing registration with Allegheny College.
∑ I plan on staying in a hotel.
∑ Holiday Inn Express
∑ Days Inn
∑ Econo Lodge
∑ Hampton Inn
∑ Quality Inn ∑ Other
∑ I plan to stay on campus in a DORM ROOM.
∑ I plan to stay on campus as a CAMPER.
∑ I plan on staying at home or w/ friends or family.
For riders staying off-campus only: If you are staying at a
hotel or at home, you will need to purchase a $10 meal pass to
join us for any meal on campus (dinner/breakfast). Do you plan
on purchasing a meal pass?
∑ Yes ∑ No ∑ Unsure
NON-REFUNDABLE REGISTRATION FEE:
∑ $65 Registration Fee from June 8th to June 13
REGISTRATION PAYMENT:
Registration Fee:
$__________
Meal Pass*:
$__________
Personal Donation:
$__________
TOTAL ENCLOSED: $__________
PAYMENT CHOICES:
∑ Check Payable to the NMSS
∑ Please charge my Credit Card:
Credit Card #: ____________________________________
Exp. Date: _____________ CVV # _________________
Authorization Signature:
________________________________________________