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Pledge Form - Rock'n August International Car Show

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					To register please fill out the following form (print clearly).

Name: ______________________________________________________________________________________

Address: ____________________________________________________________________________________

City/Town: _________________________ Prov: ______ PC: _______                                       Please send me information updates for:
                                                                                                              ADF        Rock’n August
Phone: (______) ___________________________                                                                 Please do not send me updates

                                                                                                               I prefer my updates via:
E-Mail Address: ___________________________________________
                                                                                                             E-Mail             Canada Post

Club Affiliation: 1. ____________________________________ 2. _____________________________________

Car Registration: Minimum $25 pledge for registered vehicle. Consolidated tax receipt will be issued.
                                                                                                                 Competition                            Pledge $
           Year                        Make                                 Model
                                                                                                                   Class #                               Raised
 1                                                                                                                                                  $
 2                                                                                                                                                  $
 3                                                                                                                                                  $
                                                                                                                Total $ Enclosed                    $

Payment Selection: (please check one)

      Cheque (make payable to ADF – Diabetes Research)                                       Visa                                     Mastercard
                                                                     Card #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _                               Exp. _ _ / _ _


Print full name of cardholder:_______________________ Authorized Signature:_____________________________
                                             Mail Registration to: ADF 1-020 Li Ka Shing Centre, University of Alberta,
                                             Edmonton, AB T6G 2E1 Notice: Mail Deadline is July 23, 2012
                                             Notice: Fax (780.492.6046) & e-mail (lori.mcconnell@afdr.ab.ca) deadline is July 31, 2012.

All events will be hosted in the beautiful                                                      Please    contact      the   host   hotel:    St.       Albert   Inn   at:
City of St. Albert only 3km north of the                                                        (780)459-5551 or 1-800-450-8612 for accommodations or
City of Edmonton                                                                                contact   the    St.    Albert   Tourist    Information      Centre    for
ALL EVENTS GO RAIN OR SHINE!!                                                                   alternate accommodation requirements at (780) 459-1724.
                                                                              Trophy Placings
                                                                         st       nd   rd
#              Vehicle Description             Class Description     1          2    3      10 Best
1              Antique GM to 1949             Original or Restored
2           Antique GM 1950 – 1959            Original or Restored
3           Antique GM 1960 – 1987            Original or Restored
4             Antique Ford to 1949            Original or Restored
5          Antique Ford 1950 – 1959           Original or Restored
6          Antique Ford 1960 – 1987           Original or Restored
7            Antique Mopar to 1949            Original or Restored
8         Antique Mopar 1950 – 1959           Original or Restored
9         Antique Mopar 1960 – 1987           Original or Restored
10                  GM to 1987                Original or Restored
11                 Ford to 1987               Original or Restored
12                Mopar to 1987               Original or Restored
13              All Makes to 1987               Radical Custom
14            Corvette 1953 – 1987            Original or Restored
15            Corvette 1953 – 1987                  Modified
16                Foreign to 1987                 2 Passenger
17                Foreign to 1987                 4 Passenger
18                  Sports Cars                 2 Seats, 2 Doors
19           Pony Cars 1964 – 1968                    Ford
20           Pony Cars 1969 – 1987                    Ford
21           Pony Cars 1967 – 1969             Camaro / Firebird
22           Pony Cars 1970 – 1987             Camaro / Firebird
23    Extinct or Orphaned Manufacturers
24              Street Rod to 1932
25           Street Rod 1933 – 1949
26          Convertible GM to 1987
27          Convertible Ford to 1987
28         Convertible Mopar to 1987
29                  Volkswagen
30             Muscle GM to 1987              Original or Restored
31            Muscle Ford to 1987             Original or Restored
32           Muscle Mopar to 1987             Original or Restored
33             Muscle GM to 1987                    Modified
34            Muscle Ford to 1987                   Modified
35           Muscle Mopar to 1987                   Modified
36                Pickup to 1959              Original or Restored
37             Pickup 1960 – 1987             Original or Restored
38                Pickup to 1959                    Modified
39             Pickup 1960 – 1987                   Modified
40       Limos, Hearses & Ambulances
41      Special Interest – Unusual Autos
42   Classics of the Future: 1988 – Present
43                  Motorcycle
44                  Studebaker
45             Competitor’s Choice
46                Mayor’s Choice
47     Long Distance Award – Individual
48        Long Distance Award – Club
49                People’s Choice
50              Club Participation
51                  ADF Choice
  PARTICIPANT NAME: __________________________________ PARTICIPANT PHONE #: _______________________

  PARICIPANT ADDRESS: City, Province, PC: _____________________________________________________________
  SPONSOR NAME: As you wish it to appear                          SPONSOR HOME ADDRESS: (please print clearly)                                                                      Tax
                                                                                                                                                    Phone #        $ Amount
    on the tax receipt (please print clearly)             Tax receipts cannot be issued to individuals at a business address.                                                      Rcpt?




                                                         Please make cheques payable to: ADF – Diabetes Research
                                                          Donor information must be completed in a legible manner. We cannot guarantee that tax receipts will be given if the
                                                          information is not legible. Donations of $25 or more are automatically receipted. Donations of less than $10 will not be
1-020 Li Ka Shing Centre, U of A, Edmonton, AB T6G 2E1    receipted. Alberta Diabetes Foundation does not share or distribute any of your personal information with anyone outside ADF.
      Ph: 780-492-8702 Toll Free: 1.800.563.2450
                                                          ADF collections your personal information in order to process your donation ad provide you with additional information about
       Fax: 780.492.6046 Web: www.afdr.ab.ca
                                                          diabetes research updates, ADF fundraising events and other ADF programs.
           E-Mail: lori.mcconnell@afdr.ab.ca
            Business No. 88809 8449 RR0001
                                                               LEVEL THREE                   LEVEL TWO                  LEVEL ONE
                       BENEFITS
                                                              COLLECT $1,000                COLLECT $500               COLLECT $100
                   Free Registration

                 Rock’n August T-Shirt

             One Free Hamburger & Beer


                     $50 Gas Card


                     $100 Gas Card




               In honor of the 15th Anniversary of Rock’n August there have been additional incentives added to the program.

                        BENEFITS                              Top 5 Fundraisers           Top 15 Fundraisers         Top 150 Fundraisers
              Tour of the World Renowned
               Alberta Diabetes Institute

    Unique “Rock’n August – Top Fundraiser” T-Shirt

Lead the Friday Night Car Cruise & a Preferred Stall at the
                 Saturday Show’n Shine

				
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