| 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 |
| THANK YOU FOR PARTICIPATING! | ||
| If you have any questions, Please Call (937) 366-6657 | ||
| Sponsor (Name & Address) | Amount Sponsored | Donation | Amount Collected |
| Total Collected |