Download Report

2015 L’Arche North Bay Community Walk Pledge and Waiver Form
Walk with us for our "Hole in the Wall"/Renovation Project on Saturday May 2, 2015
***** PLEASE PRINT LEGIBLY *****
Walker's Name:
Address:
Telephone #:
Email:
Please make cheques payable to L'Arche North Bay. Receipts will be automatically issued for donations of $10.00 or more.
City:
Last Name
First Name
Address
Postal Code:
Postal Code
Email*
Phone No.
Pledge
Amount
Collected?
Cash/cheque
1
2
3
4
5
6
7
8
9
10
11
12
Total
* Provide your email address if you would like to be added to the L'Arche North Bay mailing list.
Running out of space?
Add names on reverse.
WAIVER: The undersigned, on his or her own behalf, and on behalf of his or her heirs, executors, administrators, successors and assigns, hereby releases L'Arche North Bay, all event sponsors, organizers, and
volunteers, their officers, employees, servants and agents (the "Releasees") from any and all liability and waives any claims against the Releasees for injury or damage sustained by the undersigned in connection
with his or her participation in this event. The undersigned, acknowledges that he or she is aware that this involves walking, and that walking can lead to injury or damage, and confirms that the undersigned is in
proper physical condition to participate in the event. The undersigned, further consents to the use by the Releasees of his or her name and likeness in any broadcast, telecast or written account of this event.
Signature of participant:
Date:
Signature of guardian (if under 18 years of age):
Date:
***** PLEASE PRINT LEGIBLY *****
Please make cheques payable to L'Arche North Bay. Receipts will be automatically issued for donations of $10.00 or more.
Last Name
First Name
Address
Postal Code
Email*
Phone No.
Pledge
Amount
13
14
15
16
17
18
19
20
21
22
23
24
25
26
* Provide your email address if you would like to be added to the L'Arche North Bay mailing list.
Community Walk on May 2nd at the North Bay Waterfront's Rotary Rotunda
Registration : 10 am - 10:30 am
Walk : 10:30 am - 12 pm
Pre-register by contacting the L'Arche office.
L'Arche North Bay thanks you for your contribution.
Visit us at www.larchenorthbay.ca, call 705-474-0081 or email [email protected].
Change the world, one heart ( and step ) at a time.
Total Cash:
Total Cheque:
TOTAL
PLEDGES
Collected?
Cash/cheque