’06 CBBT On-line Registration Form

’06 Mail-In Registration Form

Chesapeake Bay Asthma Ride Bike Tour

& In-Line Skating

Title _____ First Name _____________________ Last Name ___________________

Business Name _________________________________________________________

Address _______________________________________________________________

City ______________________________ State __________ Zip _______________

Email _________________________________________________________________

Home Phone _____________________ Business Phone _____________________

Does Employer Have a Gift Matching Program: Yes or No (Circle One)

Sex: Female or Male (Circle One) Date of Birth: _______________________

T-shirt Size: _______ (Choose: S, M, L, XL, XXL, XXXL)

Name of roommate: _________________________ (Optional)

Are you a Team Captain? Yes or No (Circle One)

Team Name ___________________________________________________________

Team Captain Name __________________________________________________

How did you hear about the Chesapeake Bay Asthma Ride Bike Tour & In-line Skating?

Choose One:

q ALAM Email

q Word of Mouth

q Received Brochure in Mail

q Returning Rider

q Television

q Internet

q ALAM Website

q Metro Sports Ad

q Spokes Ad

q Picked-up Brochure at a Business

q Other

Two-Day Skater—Full Weekend Option	Cost:	Your Fees:
Individual	$95
Team (4 or more)	$80
Super Team (10 or more)	$75
Child (12 & under) *Child pledge minimum $100	$55
All Two Day Guest	$80
Participant PLEDGE MINIMUM (Each skater)	$200	$200
Housing Upgrade (Each skater)	$45

Total Due =

One-Day Skater—Saturday Only Option	Cost:
All Skaters *Child pledge minimum $50	$45
All One Day Guests	$35
Participant PLEDGE MINIMUM (Each skater)	$100	$100
All One Day Guests	$35
Participant PLEDGE MINIMUM (Each skater)	$100	$100

Total Due =

In case of an Emergency:

Relationship
Name*
Address
City
State
Zip
Contact Phone*
Home Phone
Cell Phone

Waiver:

I agree as a participant to follow all rules of the Chesapeake Bay Asthma Ride Bike Tour & In-line Skating (CBARBT), offered by the American Lung Association of Maryland:

I acknowledge that the In-line Skating will require strenuous physical activity and endurance and that it involves risk of injury and accidents.

I certify that to the best of my knowledge, I have no physical condition which will be aggravated by the activity and endurance anticipated or which will impair my ability to participate in and withstand the contemplated activities.

In consideration for accepting me as a participant in the CBARBT, I assume all risk of damage or injury which may be suffered by me as a result of my participation in the In-Line Skating event and agree that the above named institutions, their agents and employees, will not be liable for any damages directly or proximately caused by any act, happening, or event other than those occasioned solely by the negligence of said institutions or their agents.

I grant full permission to any and all of the foregoing to use my likeness participating in this event without obligation or liability to me.

I understand that my obligation for the Chesapeake Bay Asthma Ride Bike Tour & in-line Skating is to pay a registration fee and collect the pledge minimum. Before I skate the CBARBT, I must show that I have paid my registration fee and raised the minimum pledges that are required by me as a participant, which may be a combination of collected pledges and sponsors. After 6/4/06, I understand that I am responsible for those uncollected pledges that represent the minimum and that I have until 7/15/06 to either collect the outstanding amount or pay the amount myself.

I understand that I am required to submit 75% of my required pledge minimum to the Lung Association by 6/2/06 in order to participate.

I agree to the terms that are stated in the waiver above.

Participant Signature Date

Two-Day Skater—Full Weekend Option

Individual

One-Day Skater—Saturday Only Option

All Skaters