CONKLIN CENTER WALK

JUNE 14, 2008

At the Conklin Center for the Blind, 405 White Street, Daytona Beach
Walk Registration Form
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First & Last Name (please print)  ______________________________________________________

Street Address:  _________________________________ City:  _____________________________

State:  _____  Zip:  _____  Male _____  Female:  _____  Email:  _____________________________

Club/School/Organization:  ___________________________________________________________

Credit Card Number (if charging pledges):  ______________________________________________
                                                                                                        (MasterCard, Visa, American Express & Discover)

Signature:  _______________________________________________________________________

I hereby release Florida Lions Conklin Centers for the Blind, 405 White Street, Daytona Beach, FL  32114, or any affiliate of said organizations and Daytona Beach Community College, its Officers, Employees, Agents, Subsidiaries, Contractors and Sub Contractors from any and all liabilities for accident or injury which might occur during my participation in the annual “Conklin Center Walk-A-Thon.”

All participants need to sign and those under the age of 18 must have a parent or guardian signature too.

NO EXCEPTIONS PLEASE!


_______________________________________     _______________________________________

WALKER’S SIGNATURE                                        Parent or Guardian if under 18 years of age


FOR INFORMATION OR QUESTIONS PLEASE CALL 386-258-3441

·          Pre-registration is not necessary.  Registration is from 7 - 8 a.m.  Free refreshments are provided.

·          Walk begins at 8:00 a.m. sharp! and will conclude no later than 9 a.m.  (All participants must be back at the Center by 9 a.m. for the awards ceremony and prize giveaways.)

·          Walk is free to participate, but sponsor pledges are strongly encouraged.

·          Free event shirts to all walkers with total donations of $20 or more (students and graduates of the Center $10).  Shirts are given the day of the event on a first come, first served basis.  Sizes are not guaranteed although we do our best to accommodate.

·          Walkers who are visually impaired or require assistance will be provided with a companion walker.

·          Award ceremony will be held when all walkers have returned or no later than 9:30 a.m.

·          Breakfast is available at the Center from 7:30 to 9:30 a.m. for $3 per plate. 

·          RAISE $100 OR MORE AND GET A CHANCE TO WIN A 4-NIGHT CABIN VACATION IN THE North Carolina MOUNTAINS!

THANK YOU DELAND LIONS CLUB!
Form your team now!!!!

PLEASE USE THE SPONSOR DONATIONS FORM ON THE BACK!



 

Sponsor Donations Form

** All money MUST be turned in the day of the walk.  No “pledges” will be accepted for prize totals.**

Sponsor Name

$ Donation Amount

Sponsor Name

$ Donation Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL THIS COLUMN

 

TOTAL THIS COLUMN

 

Circle one:

Cash -- Credit Card -- Check

GRAND TOTAL
AMOUNT DUE:

 $

Please use additional sheets if necessary.

 

Everyone who raises $100 or more gets a chance to win a
4-night cabin vacation in
North Carolina!!!

 

100% of the proceeds benefit the programs at the Center. 

Thank you for your participation!!

 

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