Author: Dawn

WALKER’S PLEDGE FORM
Walker’s Name __________________________________________________
Address________________________________________________________
City__________________ State___________ Zip Code__________________
Home Phone___________________ Cell Phone _______________________
E-mail Address __________________________________________________
Church/Group ___________________________________________________
My Goal is to raise $ _________
To participate in the Walk for Life, you must sign the following release:
In consideration of the acceptance of this entry, I waive all claims for myself and my heirs against the Laurel County Life Center for any injury or illness which may result directly or indirectly from my participation. I further state that I am in the proper physical condition to participate in this event. In addition, I also give the Laurel County Life Center permission to use photographs of me taken at the Walk for Life and associated events in future event promotion.
__________________________________
Walker Signature

Please be sure to print clearly—Include zip codes & the amount each person is pledging. Thank You!!

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #_________ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #________ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $_________
Paid Bill Me One Time Gift
Cash Check Check #_______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check # _______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code ______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

Sponsor Name ____________________________________________________________
Address _________________________________________________________________
City________________________________ State__________ Zip Code _______________
E-mail Address ____________________________________________________________
Pledge: $20 $30 $40 $50 $100 Other $___________
Paid Bill Me One Time Gift
Cash Check Check #______ Donate Monthly

***OFFICE USE ONLY***
Pledges to be Billed _________ Pledges Paid in Cash __________ Pledges Paid in Check ________ Total Amount Pledged _____________

You can also give online @ www.laurelcountylifecenter.org