Printable REGISTRATION FORM - MS WALK APRIL 6, 2003 - Use for Mail-In Registration ONLY!
Please print this page , clearly PRINT all info requested using a pen
and mail to the address provided below!

Mr. [ ] Mrs. [ ] Ms. [ ]
First:___________________________ MI:____ Last:_______________________________
Address:___________________________________________
City:___________________________State:________Zip:___________________
Phone: home (_____)_________________________ office(_____)________________________
E-mail_____________________________________
Date of birth:________________________ Sex: M [ ] F [ ]
Fundraising Goal $_________________
[ ]I plan on becoming a Gold Toes Club Member (pledge $500. or more)
[ ]I plan on becoming a 2003 Club Member (pledge $2003. or more)

Employer:___________________________________________
Employer address:___________________________________________
City:___________________________State:________Zip:___________________
[ ]My company has a matching gift program
I will walk in: [ ]Fairfield [ ]Litchfield [ ]New Milford
Participate as a team (each team member must complete a separate form)
Team Name:_______________________________________
Team Captain:_______________________________________
Team Type: [ ]Friends/Family [ ]Corporate [ ]Club/Organization [ ]School [ ]Place of worship
Representing (name of org.)_____________________________

[ ]I would like more information on forming a team
[ ]I would like help with my fund-raising efforts
I Want to Help
[ ]I am walking, and would also like more information on volunteering before and after the walk.
[ ] I am unable to walk but would like to volunteer on Sunday, April 6 [ ] as an individual [ ]with a group
[ ]I can volunteer in the office [days [ ]evenings [ ] Saturday, April 5

Please send me:
[ ]_____ brochures and ____ posters to distribute and display in my neighborhood and workplace.
[ ] A press release to include in my company newsletter.
[ ] I am unable to participate, enclosed is my tax-deductible contribution of $______________
[ ] Please send me information about multiple sclerosis and the NMSS.

Mail completed form to:
National MS Society, MS Walk, One Selleck Street, Suite 500, Norwalk, CT 06855
or fax to (203) 831-2973