The SWMSTC

MS Challenge Team Entry Form

We are raising money for

............................................................. MS Therapy Centre

Our Team Name is

Our MS Passenger (if known)is

Team Leader's Name (for all correspondence)
Contact Address

Day Time Phone No.
Fax No.
Evening Phone No.
email

We would like to reserve a starting slot. Our preferred time is
______am/________pm on Saturday 19th June

Note: we will do our best to allocate your chosen time but it cannot be guaranteed

Signed by Team Leader

Print Team Leader Name

Date

Our team agrees to be bound by the rules of the Challenge.
We accept responsibility for the safety of our passenger

THANK YOU FOR YOUR SUPPORT

Please return your completed form to -
MS Challenge ---- MS Therapy Centre

For Official use only : Centres must send copies of completed forms and entry fees to:
Peter Horne at Solent MS Therapy Centre, Portsmouth
as soon as received from the team/s
No entries can be accepted after Friday 5th June 2010