PADRES Contra El Cáncer • 10220 Riverside Drive, Suite B, Toluca

PLEDGE FORM
Participant’s Last Name
Participant’s Name
Middle Initial
Address
City
State
Home Phone
E-mail
Work Phone
City:
Mobile
Birth Date
/
(mm/dd/yyyy)
/
TEAM SPONSORS
State:
Zip Code:
Name:
Address:
City:
State:
Zip Code:
Name:
Address:
City:
State:
Zip Code:
Name:
Address:
City:
State:
Zip Code:
Name:
Address:
City:
Gender
q Male q Female
For Internal Use Only
Team Code
Method of Payment: q CASH q CHECK
q VISA q MasterCard
Name:
Address:
Zip Code
State:
Zip Code:
Card #:
Pledge: $
Tel:
Method of Payment: q CASH q CHECK
q VISA q MasterCard
Card #:
Pledge: $
Tel:
Method of Payment: q CASH q CHECK
q VISA q MasterCard
Card #:
Pledge: $
Tel:
Method of Payment: q CASH q CHECK
q VISA q MasterCard
Card #:
Pledge: $
Tel:
Method of Payment: q CASH q CHECK
q VISA q MasterCard
Card #:
Pledge: $
Tel:
q AMEX
q Discover
q AMEX
q Discover
q AMEX
q Discover
q AMEX
q Discover
q AMEX
q Discover
Exp:
Exp:
Exp:
Exp:
Exp:
Sec. ID:
Sec. ID:
Sec. ID:
Sec. ID:
Sec. ID:
Collected pledge money must accompany this form. Please make checks payable to PADRES Contra El Cáncer. Cash may be presented at the
Registration Desk, but please DO NOT MAIL CASH with this form.
Please collect all contributions in advance and mail them to PADRES Contra El Cáncer, or turn them in at the appropriate Registration Desk the day
of the Run / Walk.
PADRES Contra El Cáncer • 10220 Riverside Drive, Suite B, Toluca Lake, CA 91602 • Tel. 818.980.0208 • Fax 818.980.0238
Please feel free to copy this form as needed. Additional forms can be downloaded online at www.StandforHOPE.net.
PADRES Contra El Cáncer and related designs and slogans used herein are trademarks of PADRES Contra El Cáncer, a 501(c)(3) tax-exempt organization. © 2013 PADRES Contra El Cáncer. All
rights reserved.