Fight CF Bike-a-thon

Benefiting the Cystic Fibrosis Foundation

Pledge Form                         

Participant Information:

 Please print clearly in the spaces provided below

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First Name                                                                     M.I.   Last Name              

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 Business Name
 

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Mailing Address                                                                                        Suite/Apt. Number

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City                                                                         State                                        Zip

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Phone (mandatory for credit card payment)                            e-mail address                                                          

Estimated biking speed:

Please estimate so that you may be grouped to begin the race at the same time as other bikers that will

ride at the same pace

____20miles/hr or greater   ____15-20miles/hr    ____10-15miles/hr   

 ___5-10miles/hr                ____5miles/hr or less

Here is my commitment!(min donation $20 and registration by Sept 4^th to receive a T-shirt)

Pledges are tax deductible to the fullest extent of the law.

______ $20                 _______$50                ______$100

             $30                 _______$75                           other $

Personal check – please make checks payable to the Cystic Fibrosis Foundation

Please indicate the event in which you are participating by writing “CF Bike” in the memo

portion of your check and send all pledge forms and payments directly to:

Stephanie G. Stewart

Metro DC Chapter

Cystic Fibrosis Foundation

C/O Carolyn Wolfe

13606 White Barn Lane

Herndon, VA 20171

Please indicate your preferred T-shirt size and we will do our best to get the requested

size:

 ___ S  ___ M  ___ L  ___ XL  ___ XXL  ___ 3XL ___4XL ___5XL

I HAVE READ AND UNDERSTAND THE ABOVE

Signature:                                                                                                Date:                                  

FULL WAIVER AND RELEASE

I have decided to participate in the Fight CF Bikeathon, which involves a biking event of twenty miles.  I confirm that I am participating in the Event at my own risk and hereby waive all claims of every nature against the CFF, its officers, employees and trustees, organizers, officials and  sponsors, in respect to any loss, illness, bodily injury, or death resulting from my participation in the Event.  I fully understand the rigors of such a competition and I agree to prepare for the Event if necessary. At the time of registration for the Event, I agree to inform the Event organizers of any relevant medical condition. I agree to follow the rules, which govern trail biking.

I hereby authorize and give my full consent to the CFF to copyright and/or publish any and all photographs, videotapes and/or film in which I appear while participating the Event. I further agree that the CFF may transfer, use or cause to be used, these photographs, videotapes or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, and television programs without limitations or reservations.

Because of health risks to people with cystic fibrosis (CF), individuals with CF who have had a confirmed positive sputum culture for Burkholderia cepacia complex shall not attend events sponsored by CFF. This policy is necessary because B. cepacia is contagious to individuals with CF. B. cepacia can be transmitted through casual contact or close proximity with infected individuals. B. cepacia infection in a person with CF can cause serious respiratory illness and, in some patients, may result in rapid decline in lung function, possibly leading to death. While this policy should reduce the risk of B. cepacia cross infection, there still might be some individuals with B. cepacia in attendance. B. cepacia is not a known health risk to individuals without CF who are otherwise healthy.  CFF supports research to identify new treatments for B. cepacia. For more information regarding this policy, please contact CFF or consult your physician with medical questions.

I acknowledge that I have read the above waiver and release and I understand its meaning that I have given up rights by accepting this waiver and accept it voluntarily.

Participant signature_______________________________________________________

Printed name________________________________________Date_________________

Guardian’s signature_______________________________________________________

IF UNDER THE AGE OF 18 YEARS. YOU MAY BE REQUIRED TO SHOW VALID I.D.

Printed name________________________________________Date_________________

In case of emergency, please notify___________________________________________

Daytime Tel No._________________________Evening Tel No.____________________

Known medical conditions/allergies___________________________________________

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