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[Memorial Lawn Signs]

Pledge Form

Print this form and complete.  Bring this sheet AND any collected donations to the Freedom Run on Saturday, July 3, 2010.
Sponsor Name

Phone

 Donation Collected
     John Smith (920) 455-5555 $      15.00 $      15.00
1. (      ) $ $
2. (      ) $ $
3. (      ) $ $
4. (      ) $ $
5. (      ) $ $
6. (      ) $ $
7. (      ) $ $
8. (      ) $ $
9. (      ) $ $
10. (      ) $ $
11. (      ) $ $
12. (      ) $ $

      

Totals $

 $ $
  1. Please total all donations before the event.
  2. Bring the completed sponsor sheet AND any collected donations to the Freedom Run on Saturday, July 3, 2010.   (Please make a photocopy if you need it after the event.)
  Name

MAKE CHECKS PAYABLE TO

 Address

St. Nicholas Hospital Freedom Run

 City
and mail to: State Zip

Community Education

Telephone

St. Nicholas Hospital

 E-mail

3100 Superior Avenue

 Circle one:    MasterCard       Visa

Sheboygan, WI  53081

 Number: ________ - ________ - ________ - ________
  Exp. date: ________/________    Amount: $________