2011 Fall Colour Ride Pledge Form - Hully Gully

Saturday, October 1st, 2011
Registration: From 11am
Club Challenge Cup for Club with highest sponsorship!
2 Tickets on WestJet airlines for the top fundraiser!
To register, collect pledges and pay pledges online, go to www.childhealth.ca/hullygully
NAME &/or BUSINESS: ________________________________________________
ADDRESS: ___________________________ CITY: _________________________
P.C. __________________ PHONE: ______________________________________
PLEASE PUT YOUR CLUB NAME IF YOU ARE A MEMBER: ______________________________
Hiscox Eligible? ___________
PLEDGE SHEET:
To ensure proper receipting – please print clearly and include complete mailing address and postal code
Extra sheets can be photocopied or printed from www.hullygully.com
Supporting Children’s Hospital of Western Ontario
(Receipts issued for donations of $25 or more if requested)
Amount Amount
Pledged Collected
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code

Name
Phone
Pledged Collected
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code
Name
Phone
Apt – Address
City Prov. Postal Code