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Pledge Sheet

Celiac Walkathon and Picnic of Connecticut--Saturday May 14, 2005

Walker Information/Pledge Sheet

Sponsor's Name and Address Tax Deductible Pledge
My own donation  
   
   
   
   
   
   
   
   
   
   
   
   
   
   

                                                                                                                 Total________________________

Please attach a plain sheet of paper for additional pledges.

Please collect money at the time that the pledge is made.  Checks may be payable to the Greater New Haven Celiac Group and are tax deductible.

Participant's Name________________________________________Address_________________________________________________
The first 30 walkers will receive T-shirts.  Additional shirts may be purchased for $8.00.

Team Name/Team Captain__________________________________________________________________________

City______________________________________________State________________________Zip___________________

Phone__________________________________________________(H)__________________________________________(W)

E-mail______________________________________________________Date of Birth_______________________________

I, the undersigned, waive all claims against CSA/USA, the Greater New Haven Celiac Group, and event sponsors and personnel for any injury I might suffer in this event.   I attest that I am physically fit and prepared to participate in the Celiac Walkathon of Connecticut event.  I grant full permission to the event organizers to use photographs and quotations from me in legitimate accounts and promotion of the walk.

Signature____________________________________________________________Date______________________________________
               (Participant or Parent/Guardian)

Each person 18 years of age and over must complete a registration form and pay the registration fee. Early Registration: $15 Registration after April 29, 2005: $20.00

I have enclosed registration fee of __________.

Please mail registration form, registration fee and collected pledges to:

Betsey Powers, 7 Justine Dr., North Haven, CT 06473

Registration forms, fees and pledges may also be submitted on the day of the walk.

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