Florida Lions
Conklin Center WALK-A-THON
June 19, 2004

At the Conklin Center, 405 White Street, Daytona Beach
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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, Smerican Express, & Discover)

Signature: ________________________________________________

I hereby release the Florida Lions Conklin Centers for the Blind, 405 White Street, Daytona Beach, Florida 32114, or any affiliate of said organizations and International Speedway Corporation, 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 Cneter Walk-A-Thon."

Participants under the age of 18 must have this form signed by a parent or guardian. NO EXCEPTIONS!

_____________________________________     ___________________________________
Participant's Signature                                         Parent or Guardian's Signature


FOR INFORMATION OR QUESTIONS PLEASE CALL 386-258-3441

THANK YOU to our sponsors!

Daytona Beach Community College - Daytona Beach Visitors and Convenion Bureau - more to come!

PLEASE USE THIS PLEDGE FORM!
Sponsor's Name Address Phone Number Total $
       
       
       
       
       
       
       
       
       
       
       
       
       
       
       
AMERICAN EXPRESS/DISCOVER/MASTERCARD/VISA ACCEPTED TOTAL COLLECTED:

_______________
100% of all contributions benefit programs of the
Florida Lions Conklin Centers For The Blind,
Florida Permit #SC00798.

REMEMBER:  To bring this and your pledges with you to the Walk-A-Thon.

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