(For Office Use Only)
Name of Runner/Walker:
Address:
Phone Number:		Postal Code:
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Please make cheques payable to Bereaved Families of Ontario. TOTAL PLEDGED                            Receipts for income tax purposes are issued  for pledges of $10.00 or more. TOTAL REMITTED

Instructions: In order to be eligible for great prizes, please complete your pledge form and collect the money before Race Day.  Bring both the completed form and all pledge money to the Pledge Table by 7:00pm on Race Day.