Suffolk Chapter of
The Cooley's Anemia Foundation, Inc.
"Miles for Smiles" Ride and Walk
740 Smithtown By-pass, Suite 201
Smithtown, NY 11787
Phone: 631-863-0532

Participant Name:
Home Address:
Address 2:
Address 3:
City:
State:
Zip:
Country:
Telephone:
Email:
Age:

Individual or family registration (3 or more people, kids under ten free).
Distance
Registration fee
Recommended Sponsorship
(due at event)
Number of
family members
I will walk:
4 miles
$20
$20
1
I will cycle:
4 miles
$20
$20
1
I will cycle:
20 miles
$30
$20
1
I will cycle:
62 miles
$50
$50
1
My family will walk:
4 miles
$30/family
$30/family
My family will cycle:
4 miles
$30/family
$30/family
My family will cycle:
20 miles
$50/family
$40/family
My family will cycle:
62 miles
$75/family
$50/family

I am unable to ride or walk, but would like to make a contribution:
contribution:
-
$
 - -
Individual value of participant giveaways including t-shirt, 4 complimentary tickets to Atlantis Marine World, breakfast/lunch and rides for children is approximately $100.
A $25 gift certificate to Applebee's will be given to EACH individual registrant or ONE per family for EACH FAMILY registration in the 100, 62 or 20 mile bike ride THAT SUBMITS THE MINIMUM SPONSORSHIP.
   
I want to start a team - please contact me
I am a team member
Team Name:
Team Captain Name:
Team Captain Phone Number:
Prize for team with most members for 62 and 20 mile bike ride.

T-shirts (1 per person):
 S M L XL XXL
 
Please send me:
Volunteer information, as I am unable to ride or walk
Volunteer information for family and friends
Brochures # Posters #
Pay by Credit Card
Note: If you cannot pay by credit card, please contact The Cooley's Anemia Foundation at the phone number or address above.
Cardholder Name:
Click here if billing address is same as participant's address above
Otherwise enter billing address:
Billing Address:
Address2:
Address3:
City:
State:
Zip:
Country:
 
Credit Card Number:
Exp. Date:
 /

Disclosure Agreement:
In submitting this form for myself, I understand and I agree to absolve Cooley's Anemia Foundation and all sponsors, be they individuals or organizations, of all blame for any injuries, misadventure, harm loss, inconvenience suffered in any of the activities associated with the said event. I also agree that photographs be taken of me and used for publicity purposes.

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