10th Annual "Walk for a Guide Dog"
Fundraiser - Oct 15, 2017
REGISTRATION FORM
Print Name:_____________
Address/City/State/ZIP:____________________
Phone: _________________
E-Mail:____________________
I will be walking. Enclosed is my $20 Registration fee:_______
( $15 before October 10, 2017 )
I am unable to walk, but please accept my donation of $______
I want to be a T-Shirt Sponsor. Please accept my donation of $100 enclosed (No later than September 30, 2017)
Print Name to be on T-Shirt:__________________________
I want to be in the 50/50 Contest. (Min $5 per ticket). $ ______ enclosed
Make checks payable to: Lions Club of The Islips, P.O. Box 91, East Islip, NY 11730
Waiver: The undersigned does hereby acknowledge that he/she is aware of risk of injury of walking the 2 miles, but is willing to accept all risks and hereby states that he/she is in good physical condition. I hereby release all sponsors of the Lions Club of The Islips from any injury or losses suffered because of this event. I give full permission to use my name or photograph in connection with this event. Children under 14 must be accompanied by parent.
Signed: ____________________ Date: ________________
