Date of Birth (Must Be at Least 12 Years Old to Participate) Male Female

SEPTEMBER 10-12, 2010 WWW.MSBIKE.ORG REGISTER TODAY!

Name Address City, State, Zip Phone (H) (W) E-mail

Date of Birth (must be at least 12 years old to participate)  Male  Female Employer T-shirt size:  S  M  L  XL  XXL EMERGENCY CONTACT INFORMATION - REQUIRED Name: Relationship:

(NOT SOMEONE ON THE ROUTE) Phone Number: (H): (M):

TEAM INFORMATION Team Name

Team Captain’s Name

Type:  Corporate  Friends/Family  Club/Organization  School  Place of Worship I commit to raise $______for MS! ($200 minimum to be turned in by event date) -Jewelry Boomerang ($1,000) -National Tour of Champions ($7,500) -Mission Possible ($4,900)

MY ROUTE CHOICES Saturday:  30 miles  50 miles  75 miles  100 miles Sunday:  30 miles  50 miles  75 miles  100 miles

This is my _____ year riding in Bike MS.

REGISTRATION FEE: Discount Code:  $35 Before June 1  $45 from June 1 to Aug. 31  $50 After Aug. 31 RETURN WITH CREDIT CARD INFO OR CHECK MADE PAYABLE TO THE NMSS TO: Phone registration: 1-800-FIGHT MS or 919-834-0678 Mail registrations to: National MS Society, 3101 Industrial Dr., Ste. 210, Raleigh, NC 27609

CREDIT CARD INFORMATION – REQUIRED IF YOU ARE NOT MAILING IN A CHECK

Name As Appears on Card:

Credit Card Type:  American Express  Visa  Master Card

Card #: Expiration Date:

Registration Fee: Donation Amount:

Signature:

WAIVER AND RELEASE FROM LIABILITY

(Participants over 18 years old)

I freely accept and voluntarily assume the risks of personal injury and/or property damage that may result from the National MS Society’s Bike MS event to be held on September 10-12, 2010.

I agree to hold harmless the National MS Society, corporate sponsors, cooperating organizations, and all parties connected with this event from any liability as a result of my participation. I will permit emergency treatment in the event of injury or illness while participating in the event and give the National MS Society permission to use my name and photo taken during the event in any promotional material, publication, or on the website.

I agree to obey all traffic laws and rules of safety for the event and understand that the National MS Society withholds the right to dismiss anyone that may cause disturbance during this event or disregard the rules with respect to safety. I acknowledge that no trailers or carriers are allowed on the route at any time.

I also acknowledge that cyclists under the age of 12 are not permitted to ride. Cyclists between the ages of 12 and 17 must submit a signed, notarized waiver before participating in this event and must be accompanied at all times by a responsible adult at least 21 years of age (the child to adult ratio cannot exceed 3:1).

I certify that I have read and understand the intent of this waiver and release.

Participant Name (print):

Participant Signature: