REGISTRATION FORM Last Name: __________________________ First Name:_______________________ Address: ____________________________ City :_____________ Province: _______ Postal Code: ___________ Phone: ______________ Email: ___________________ Registration Type: Individual Team Team Name:_________________________ Please select: 5 KM Walk 20 KM Ride 80 KM Ride Fundraising Goal: $_________ Tshirt size: X Small Small Medium Large X Large XX Large Waiver: In consideration for participation in the 2015 Volta Luso Charities (“Volta Luso”), I waive and release any and all claims that I and/or my heirs, executors, administrators, agents, insurers, assigns and other legal representatives have or may have against Luso Canadian Charitable Society and its administrators, trustees, officers, directors, agents, employees, volunteers, successors, affiliates, sponsors and other legal representatives, both present and future for any accident, injury, illness, death or other claim, in law or equity, which may result, directly or indirectly, from my participation in Volta Luso. I permit the use of my name, amount raised, picture and video to be used in any and all forms and types of publicity produced in connection with Volta Luso or Luso Canadian Charitable Society including, but not limited to, the purposes of marketing, promoting or otherwise reporting relating to Volta Luso or Luso Canadian Charitable Society. I am physically fit to participate in Volta Luso. I have read, understand and agree with the content of this waiver/release prior to participating in Volta Luso. If participant is under the age of majority, I confirm I am the parent/guardian of participant and sign this waiver/release on his or her behalf. X___________________________________________________ Signature of Participant or Guardian (if under the age of majority) ______________ Date Notice of Registration is mandatory by either email, fax or phone before May 29th. Event location: 2991 Concession Road 4 Township of Adjala Tosorontio, Ontario 80 KM Ride 20 KM Ride 5 KM Walk Registration at 8:30 am Registration at 9:30 am Registration at 9:30 am Start at 9:00 am Start at 10:00 am Start at 10:00 am Luso Canadian Charitable Society 2295 St. Clair Avenue West Toronto, ON M6N 1K9 lusoccs.org [email protected] P:416-761-9761 F:416-761-9310 Charitable Registration Number: 860258649 RR0001 PLEDGE FORM Last Name:_________________ First Name:________________ Phone:________________ Email: _______________________ Address:_______________________ City:_______________ Province: _______________ Postal Code: ________________ Please complete all fields & print clearly. All monies are due on May 31st, 2015 & are to be submitted at the event. Cheques should be made payable to Luso Canadian Charitable Society. Tax receipts will be issued for donations over $20.00. Questions? Call 416-761-9761 or email [email protected] Name of Sponsor Mailing Address Email Address Payment Type Credit Card John Smith 123 Main St. Toronto, ON M6N 1K9 [email protected] □ Cash □ Cheque Tax Receipt Yes Credit Card Type Credit Card # (all 16 digits) Expiry Date Amount MasterCard 1234 4321 1234 4321 02/15 $100.00 □ No □ Credit Card □ Cash □ Cheque □ Credit Card □ Cash □ Cheque □ Credit Card □ Cash □ Cheque □ Credit Card □ Cash □ Cheque □ Credit Card □ Cash □ Cheque Page #____ of ____ Total this page $_____ Luso Canadian Charitable Society 2295 St. Clair Avenue West Toronto, ON M6N 1K9 lusoccs.org [email protected] P:416-761-9761 F:416-761-9310 Charitable Registration Number: 860258649 RR0001
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