Walk Information Registration Form Sponsor Pledge Sheet - PDF

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Walk Information Registration Form Sponsor Pledge Sheet - PDF Powered By Docstoc
					  Walk Information                                             Registration Form                                                                    Sponsor Pledge Sheet
  Registration                                                 Title (Mr./Mrs./Ms./Dr.): ____________________________                               Have your family, friends and neighbors go on line to sponsor you.

  Online: Pre-register online at http://www.firstgiving.com/   First Name: ________________________________________
                                                                                                                                                    Name: ____________________________________________________                       Phone: _______________________________________________
  scleroderma-chicago or http://scleroderma.org/               Last Name: _______________________________________                                   Address: __________________________________________________                      E-mail: ________________________________________________
  chapter/illinois (click on walk link).                                                                                                            City: ______________________________________________________                     State:    ________________________Zip: ___________________
                                                               Street Address: ____________________________________
  By Mail: Mail your completed registration form with          Address 2: ________________________________________                                                    Name                                        Address                             City      State      Zip        $ Pledged
  fee ($25) per walker (children under age 12 free),
  postmarked by June 19th, 2009 to the Scleroderma             City: _____________________________________________                                  1 __________________________________________________________________________________________________________________

  Foundation of Greater Chicago, 2003 N. Wabash St.            State: ______________________ Zip Code: ____________                                 2 __________________________________________________________________________________________________________________

  #2219, Chicago, IL 60601. Make checks payable to the                                                                                              3 __________________________________________________________________________________________________________________
                                                               This Address is: n Home n Work n School
  Scleroderma Foundation of Greater Chicago (or SFGC.)                                                                                              4 __________________________________________________________________________________________________________________
                                                               Daytime Phone: ___________________________________                                   5 __________________________________________________________________________________________________________________
  Walk Day: Register in-person on the morning of the walk
                                                               E-mail Address: ___________________________________                                  6 __________________________________________________________________________________________________________________
  with a completed registration form and $25. Bring your
  pledge sheets and any other contributions with you.                                                                                               7 __________________________________________________________________________________________________________________
                                                               Employer: ________________________________________
                                                                                                                                                    8 __________________________________________________________________________________________________________________
                                                               My company has matching funds: n Yes n No n Unsure
  Schedule                                                     Adult shirt size: n Sml n Med n Lrg n XLrg n XXLrg
                                                                                                                                                    9 __________________________________________________________________________________________________________________
                                                                                                                                                    10 __________________________________________________________________________________________________________________
  Start and finish is in the south parking lot of the                                                                                               11 __________________________________________________________________________________________________________________
                                                               I am a Scleroderma patient: n Yes n No
  Highland Park Metra Train Station
                                                                                                                                                    12 __________________________________________________________________________________________________________________
  (1800 St. John’s Avenue at Laurel.)                          I am a member of the: n Chapter n Support Group
                                                                                                                                                    13 __________________________________________________________________________________________________________________
  Registration: Opens at 7:30 am                               I would like more information about                                                  14 __________________________________________________________________________________________________________________
  Pick up t-shirt, enjoy Starbuck’s Coffee & Dunkin Donuts        chapters or support groups in my area: n Yes n No
                                                                                                                                                    15 __________________________________________________________________________________________________________________
                                                               I am walking as part of a team: n Yes n No                                           16 __________________________________________________________________________________________________________________
  Walk: Begins at 9:00 am
  Choose between a 1- and 3-mile walk                          If yes, name of team: _______________________________                                17 __________________________________________________________________________________________________________________
                                                                                                                                                    18 __________________________________________________________________________________________________________________
                                                               Name of team captain: _____________________________
  Highlights                                                   Affiliation (school, church, company, etc.): _____________
                                                                                                                                                    19 __________________________________________________________________________________________________________________
                                                                                                                                                    20 __________________________________________________________________________________________________________________
  Refreshments: fruit, juice and water
                                                               I am interested in volunteering for this event: n Yes n No                           21 __________________________________________________________________________________________________________________
  Carol’s Cookies and Starbucks Coffee
                                                               I am unable to participate.                                                          22 __________________________________________________________________________________________________________________
  Family Entertainment:                                           Please accept my contribution of: _________________                               23 __________________________________________________________________________________________________________________
  Kids Zone, Moonwalk, Face Painters, and Balloon Designs                                                                                           24 __________________________________________________________________________________________________________________
                                                               WAIVER: In consideration of being permitted to participate in “Stepping Out To
  Fabulous Raffle!                                             Cure Scleroderma,” I hereby, for myself, my heirs and personal representative,       25 __________________________________________________________________________________________________________________
                                                               assume any and all risks which might be associated with this event. I further        26 __________________________________________________________________________________________________________________
  Help us raise funds and awareness!                           waive, release, discharge, and covenant not to sue the Scleroderma Founda-
  Please visit the Chicago Sky Women’s Basketball Team         tion, any chapter, support groups, officers, employees, sponsors, organizers,        27 __________________________________________________________________________________________________________________
                                                               volunteers, or other representatives or their successors and assigns, for any
               table at this year’s walk!                                                                                                           28 __________________________________________________________________________________________________________________
                                                               and all injuries of damages of any kind whatsoever suffered as a result of
               Buy your tickets for the big game,              taking part in the event and any related activities. I further agree to the use of   29 __________________________________________________________________________________________________________________
               Saturday, August 1, 2009,                       any photo, film, or videotape of the event for any purpose the Scleroderma
                                                               Foundation shall determine in its discretion. I affirm that I have read and will
                                                                                                                                                    30 __________________________________________________________________________________________________________________
               benefiting the Scleroderma Foundation.          abide by the terms set forth in the “Stepping Out” Waiver, and I affirm that the
                                                               information I have given on this form is true, complete and correct.                 If more space is needed to list sponsor pledges, please photocopy and attach additional sheets.                        Total:




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  Scleroderma




                                                                            Permit No. 4722
                                                                            Non-Profit Org.
                                                                             U.S. Postage

                                                                              Chicago, IL
  Scleroderma is a chronic, often progressive




                                                                                 PAID
  autoimmune disease— like Rheumatoid Arthritis,
  Lupus and Multiple Sclerosis—in which the body’s
  immune system attacks its own tissues. The disease,
  which literally means “hard skin”, can cause thickening
  and tightening of the skin as well as serious damage
  to internal organs including lungs, heart, kidneys,
  esophagus, and the gastrointestinal track. Scleroderma


                                                                                                                                               Stepping Out
  occurs three to four times more often in women.
  For most people with Scleroderma, the disease has
  a serious impact on daily life. For many, it is a life-




                                                                                                                                               CURE
  threatening disease. And although medications can


                                                                                                                                                 To
  sometimes help, at present there is no cure.

                                                             Stepping Out
  Make a Difference
  2008 was a great year for “Stepping Out.”
  Nationally, we had 10,000 walkers, 500 volunteers,
                                                             CURE
                                                             To
                                                             Scleroderma                                                                       Scleroderma
  and over 55,000 individuals who supported a walker
   in one of our walks!. Don’t miss out on the opportunity
  to have fun, make new friends, and raise money for
  the Greater Chicago Chapter. We need you help, so
  join us to help raise money to support our three-fold
  mission of Support, Education and Research.


  Sponsors:
  Antons Fruit Ranch, Carol’s Cookies, Mirco Builders,
  Mutual Ace Hardware, Penny’s From Heaven,
  Phoebe and Frances, PLS Transport, Signs Now,
  Starbucks Coffee, Sunset Foods, Whole Foods.




                                                                                                                        National Scleroderma
                                                                                                                         Awareness Month
                                                                                                                         In recognition of
                                                                                              203 N. Wabash St. #2219


                                                                                                www.scleroderma.org
                                                                                                 Chicago IL 60601
                                                                                                                                               Seventh Annual 1 & 3 Mile Walk
                                                                                                                                                   Sunday, June 28, 2009
                                                                                                                                                   Highland Park, Illinois


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