Miles for Smiles Signup Form

Thank you for participating in Miles for Smiles!
Please CLICK HERE to download and review the waiver before submitting the form below.
If you have multiple children who would like to participate, please ensure that you submit a separate form for each child.

CONTACT INFORMATION

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

PARTICIPANT DETAILS

Participant Name

Participant Grade Level

Participant School District

Participant School

Will you be participating individually or as part of a team?

Miles for Smiles welcomes “teams” of up to 14 people.

Individual

Team

Team Name

List team name below. Please note that all team members will need to register individually.

BIKE APPLICATION

Do you need a bike in order to participate in the challenge? Adaptive bikes are available through our partner school districts. We have a number of good used condition two-wheel bikes available. Please fill out portion below to apply for a bike.

Yes (please answer the next two questions below)

No (please skip the next two questions below)

How would this bike benefit you?

Why are you signing up for the Miles for Smiles Challenge?

WAIVER

I have read and understand the waiver (at the top of this webpage) and release, accept and agree to its terms and sign it voluntarily.

Yes

Electronic Signature

If participant is under 18 years of age, signature of parent/legal guardian is required below.

Date

YYYY