Please Mail Collected Pledges to:
SATH (Supplementary Assistance to the Handicapped)
C/O Linda Allen, Executive Director
5350 W. New Market Rd.
Hillsboro, Ohio 45133
I hereby signify that I understand that SATH, Rocky Fork Lake where I will walk or roll, and all other organizations, businesses, or persons connected with this event are not to be held responsible for any injuries which I may suffer while taking part in this event or as a result thereof.  In this connection, I hereby waive any claim for damage to my person or property.
Name of Participant:______________________________________ _____________________________________  _______________
Address:________________________________________________ Participant Signature  Date
______________________________________________________ _____________________________________  _______________
Telephone Number:_______________________________________ Parent or Guardian Signature (If under 18)  Date
If you have any questions, Please Call (937) 366-6657
Sponsor (Name & Address) Amount Sponsored Donation Amount Collected
    Total Collected