|
My goal is to raise $
for Alzheimer's programs and services.
Name:
Address:
City: State: Zip:
Phone Day: Evening:
Email:
Male
Female Age:
Employer/School:
My company has a matching gift program
Yes
No
Company:
I will be walking at
Albany
TBA
Salem 10/4
I will walk as
Team
Captain Team
Member
Individual
If you are on a team, please complete the following:
Team Name:
Representing (name of organization):
Captain's Name:
I am walking in honor of:
|
Please send me the following information:
AlzNet programs
and services
Walk or other volunteer
opportunities
Information on forming a
walk team
Brochures
(indicate quantity)
Posters (indicate
quantity)
I am unable to walk, and I would like to make a
contribution:
Enclosed is my donation of
$200
$100
$50 Other Amount $
Please make checks payable to AlzNet
Waiver
and Release of Liability
I hereby waive all claims against the Alzheimer’s Network of
Oregon, sponsors, or any personnel for any injury I might suffer
in this event. I attest that I am physically fit and prepared
for this event. I grant full permission for organizers to use
photographs of me and quotations from me in legitimate accounts
and promotions of this event.
Signature:_________________________________
Date_____________________________________
(Parent or
guardian’s signature if walker is under 18 years of age)
|