Official Sponsorship Form

							                                              Official Sponsorship Form
                                          Participant Name: _____________________________________________________

                                          Address: _______________________________________________________________

                                          City, State, Zip: ________________________________________________________

                                          Phone: (home)_________________________ (cell) _________________________

                                          Email Address: _________________________________________________________

   Donor Name             Phone Number                    Address                          Donation          x    Weight Loss      =   Total Donation
                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                                                       _____________
                                                                                   $ ______ Total Donation
                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                   $ ______ Total Donation             _____________

                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                   $ ______ Total Donation             _____________

                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                                                       _____________
                                                                                   $ ______ Total Donation
                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                   $ ______ Total Donation             _____________

                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                                                       _____________
                                                                                   $ ______ Total Donation
                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                   $ ______ Total Donation             _____________

                                                                                     $ _______Per Lb. Lost
                                                                                              OR
                                                                                   $ ______ Total Donation             _____________

                       All donors will receive an official tax deductible receipt in the mail upon completion of the program.
Directions: Obtain Sponsors to pledge a dollar amount per pound of body fat lost in 30 days.       By initialing this box, I pledge to match the total
donations above if I instead gain weight. Have pledges write checks directly to Autism Speaks and mail you forms and Grand Totals to TEST Sports
                                              Clubs, 1931 Washington Valley Rd. Martinsville, NJ 08836.