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: ________________________________________________
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