how to get involved and make a difference in your community it’s easy as 1,2,3! 1 making a difference The purpose of CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada is to raise funds to help Canadians living with cystic fibrosis who urgently need a cure or control for cystic fibrosis. You can use the pledge form in this brochure to ask your network for donations. Be sure to bring it and all funds raised to the walk on Sunday, May 31, 2015 in order for your donors to receive tax receipts. You can visit us online at www. cysticfibrosis.ca/greatstrides to register and enter your donations online for your supporters to receive electronic tax receipts. 2 register There are four ways to register for CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada: ONLINE: www.cysticfibrosis.ca/greatstrides EMAIL: [email protected] CALL: 1-800-378-2233 IN PERSON: Visit us on walk day, Sunday, May 31, 2015 at one of our walk locations (contact us or visit www.cysticfibrosis.ca/greatstrides to find a walk location near you) 3 teamwork and awareness Gather friends, family, teammates, club members, and/or colleagues to form a CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada team. Motivate and encourage others to participate and support a cause that funds vital cystic fibrosis research, care and advocacy initiatives. To start building your team and raise awareness visit www.cysticfibrosis.ca/greatstrides today! The generosity of CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada donors and supporters enables Cystic Fibrosis Canada to improve the lives of Canadians with cystic fibrosis. why your support matters Cystic fibrosis affects the lungs and digestive system and is the most common fatal, genetic disease affecting Canadian children and young adults. The mission of Cystic Fibrosis Canada is to help people with cystic fibrosis. We fund research towards the goal of a cure or control for cystic fibrosis, support high quality CF care, promote public awareness of cystic fibrosis, and raise and allocate funds for these purposes. For more information about Cystic Fibrosis Canada or to donate, visit www.cysticfibrosis.ca/greatstrides today. Cystic Fibrosis Canada’s Infection Prevention and Control Policy: The health and well-being of people with cystic fibrosis is our top priority. Attendance by people with cystic fibrosis to Cystic Fibrosis Canada’s hosted or sponsored outdoor events are at the individuals’ own risk. For more information on Cystic Fibrosis Canada’s Infection Prevention and Control Policy, please visit www. cysticfibrosis.ca/about-us/infection-prevention-andcontrol thank you to our sponsors Cystic Fibrosis Canada would like to extend a tremendous thank you to our sponsors. Their passion, dedication and hard work are helping create a world where cystic fibrosis is no longer a progressive life-shortening disease. Official Title Sponsor National Walk Partners H US T I W WALKNDAY, SU 15 0 2 , 1 MAY 3 DONATE REGISTER FUNDRAISE CysticFibrosisCanada @CFCanadaWalk | @CFCanada REGISTRATION INFORMATION 1) q Please check this box if you have also registered online. If so, please write your name as you have recorded it online so that we can match your profile. 2) Please bring this form and all funds collected to your CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada walk location. Cheques can be made payable to Cystic Fibrosis Canada. If you are not able to attend the walk in person, please mail this form and include all your funds to CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada c/o Cystic Fibrosis Canada, 2323 Yonge Street, Suite 800, Toronto, ON, M4P 2C9 by June 12, 2015. First Name: Last Name: Address: Suite or Apt#: City: Province: Postal Code: Telephone (home): (business): ext.: E-mail: Language preference: q English q French Company Name: WAIVER, INDEMNITY & PHOTO RELEASE: Please read carefully I agree: 1) That at all times during CARSTAR’s Great Strides™ Walk for Cystic Fibrosis Canada, my safety remains my sole responsibility and 2) that I will discontinue from participating in this event if requested to do so by any representatives of Cystic Fibrosis Canada and 3) that I am aware of the inherent risks in participating in this event and voluntarily assume such risks. IN CONSIDERATION of acceptance as a participant in this event, I myself, my heirs, administrators and assigns HEREBY RELEASE, WAIVE and FOREVER DISCHARGE Cystic Fibrosis Canada and all its associations and sponsoring companies and all its respective agents, officials, officers, directors, employees, servants, conductors, representatives, successors and assigns OF AND FROM ALL claims, demands, payments, actions, causes of action, damages, costs and expenses, in respect of death, injury, loss or damage to my person or property HOWEVER CAUSED arising or to arise by reason of my participation in the said event AND NOTWITHSTANDING that same may have been contributed by the negligence of any of the aforesaid. I FURTHER UNDERTAKE TO HOLD AND SAVE HARMLESS and AGREE TO INDEMNIFY all the aforesaid from and against any and all liability incurred by and or all of them arising as a result or in any way connected to my participation in said event. BY SUBMITTING THIS ENTRY I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREED to the above AGREEMENT, RELEASE, WAIVER AND INDEMNITY, I WARRANT that I am physically able to participate in this event. The undersigned also grants to Cystic Fibrosis Canada, in whole or in part, the right to use the film footage/photographs of myself or of my children, produced for promotional purposes, provided that said footage/prints, in whole or in part, including voice-overs, be used exclusively by the above mentioned organization. Participant’s Name (print): PLEDGE INFORMATION Tax receipts will be issued for all donation amounts of $20 or over. All donor information below MUST be completed in order to receive a tax receipt. For electronic tax receipt requests an email address must be provided in addition to the above. 1 Donor’s Name (First/Last) Credit Phone Amount Cash Cheque q print Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code 2 Donor’s Name (First/Last) q electronic Credit Card # Expiry (MM/YY) Phone q print Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code 3 Donor’s Name (First/Last) q electronic Credit Card # Expiry (MM/YY) Phone q print Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code 4 Donor’s Name (First/Last) q electronic Credit Card # Expiry (MM/YY) Phone q print Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code 5 Donor’s Name (First/Last) q electronic Credit Card # Expiry (MM/YY) Phone q print __________________________________________________________ Team Captain Name: Team Name: (please write your team name exactly as it is registered online): Team Type: q Family and Friends Team q Corporate Team q Association or Membership Team * I n the event a parent or guardian is accompanying more than one minor from the same household, the parent or guardian is permitted to sign one waiver, as long as all participating minors are listed above. I approve and give my consent to the participation of the said minor(s) in this event and also adopt the above release for myself. q School Team Are You A Member/Employee/Family of One of the Following? q CARSTAR Canada q Kin Canada: q Siemens Canada Date:______________________________________________________ q EllisDon District #___________________ ClubName:________________________________________________TeamName:____________________________________________ q Other (Please Write Full Name): Signature (Parent/Guardian):_________________________________ ___________________________________________________________________________ Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code 6 Donor’s Name (First/Last) q electronic Credit Card # Expiry (MM/YY) Phone q print Street Address or PO Box (suite/apt./unit) City E-mail Province Postal Code q electronic Credit Card # Expiry (MM/YY) Instead of bringing cash with me to walk day, I would like to pay the following on my credit card: Amount $_____________ (you can also visit us www.cysticfibrosis.ca/greatstrides for payments) q VISA q MasterCard q AMEX Name on Card: __________________________________ Credit card#: ______________________________________ Expiry Date: _______ Signature: _______________________________________ Are you q Male Cash/Cheque/Credit Total: Include Online Total here: GRAND Total: Pg ___ of ____ q Female Please select your age range q 3 years and under q 4 - 16 Tax Receipt Request q 17 - 25 q 26 - 35 q 36 - 45 q 46 - 54 q 55 and over By completing this form and submitting to Cystic Fibrosis Canada, you hereby consent to the collection and use, by the organization of your personal information in accordance with Cystic Fibrosis Canada’s Privacy Policy. Our policy details are available by sending an e-mail to [email protected] with “Attention Privacy Officer” in the subject line, or by contacting Cystic Fibrosis Canada at (800) 378-2233. Charitable Registration: # 10684 5100 RR0001
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