Florida Lions Conklin Center Walk-A-Thon Registration

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

At the Conklin Center, 405 White Street, Daytona Beach - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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

No pre-registration necessary. Registration begins at 7:00 a.m. Free refreshments are provided.
Walk-A-Thon begins at 8:00 a.m. and will conclude no later than 10:00 a.m. (All participants must be back at the Cneter by 10:00 a.m.)
Walk-A-Thon is free to participate, but sponsor pledges are encouraged.
Free event shirts to all walkers with total pledges of $10 or more. Shirts are given the day of the event on a first come, first served basis and sizes are not guaranteed.
Walkers who are visually impaired or require assistance will be provided with a companion walker.
Award ceremony will be held back at the Center at 10:30 a.m.
Breakfast is available at the Center from 9:00 to 11:00 a.m. for $3.00 per person.

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.

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

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