Participant Pledge Form
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1Canadian Cancer Society Participant Pledge Form
RE ID
(OFFICE USE ONLY)
EVENT: Relay For Life
Jail-N-Bail
Fundraise For Life
Face Off Against Cancer
Cops for Cancer
EVENT NAME
Mr Mrs Ms Dr Other First Name: ___________________________________________ Last Name: _____________________________
DATE
Company Name (if applicable): _______________________________________ Address: _______________________________________ Apt: ________________
LOCATION
City: ___________________ Prov: ____________________ Postal Code: ___________________ E-mail Address: ______________________________
TEAM NAME
Home Phone: ________________________________ Bus Phone: _______________________________ Other Phone: _________________________
TEAM #
Please consider selecting an e-mail receipt. Besides helping the environment, the reduced administration costs will help us allocate more funds to our
mission of eradicating cancer and enhancing the quality of life of those living with the disease. All cheques made payable to: Canadian Cancer Society.
Credit card donations can be made online at cancer.ca or by calling 1 800 661-2262.
PLEDGE INFORMATION
RE ID
(PLEASE PROVIDE COMPLETE INFORMATION)
(OFFICE USE ONLY)
MR
First Name/Company Name
Last Name
Address
City
Prov.
Postal Code
Phone Number
MRS
MS
DR
Donation Type cash cheque
Cheque No.
E-mail Receipt Yes No E-mail Address
Amount $
OTHER
PLEDGE INFORMATION
RE ID
(PLEASE PROVIDE COMPLETE INFORMATION)
(OFFICE USE ONLY)
MR
First Name/Company Name
Last Name
Address
City
Prov.
Postal Code
Phone Number
MRS
MS
DR
Donation Type cash cheque
Cheque No.
E-mail Receipt Yes No E-mail Address
Amount $
OTHER
PLEDGE INFORMATION
RE ID
(PLEASE PROVIDE COMPLETE INFORMATION)
(OFFICE USE ONLY)
MR
First Name/Company Name
Last Name
Address
City
Prov.
Postal Code
Phone Number
MRS
MS
DR
OTHER
Donation Type cash cheque
Cheque No.
E-mail Receipt Yes No E-mail Address
Amount $
PLEDGE INFORMATION
RE ID
(PLEASE PROVIDE COMPLETE INFORMATION)
(OFFICE USE ONLY)
MR
First Name/Company Name
Last Name
Address
City
Prov.
Postal Code
Phone Number
MRS
MS
DR
OTHER
Donation Type cash cheque
Cheque No.
E-mail Receipt Yes No E-mail Address
Amount $
PLEDGE INFORMATION
RE ID
(PLEASE PROVIDE COMPLETE INFORMATION)
(OFFICE USE ONLY)
MR
First Name/Company Name
Last Name
Address
City
Prov.
Postal Code
Phone Number
MRS
MS
DR
Donation Type cash cheque
Cheque No.
E-mail Receipt Yes No E-mail Address
Amount $
OTHER
PLEASE NOTE THE FOLLOWING
FOR OFFICE USE ONLY
Information collected on this form will be used for the Society’s purposes only. You may obtain
Receipted
# ____________
$ __________________
Total Cash
$________________________
a copy of our privacy policy online at cancer.ca or contact us at 1 800 661-2262. Receipts will
Non Receipted
# ____________
$ __________________
Total Cheque
$________________________
be issued for donations of $20 or more, but only if the donor’s name and address are
clearly printed and complete. PLEASE DO NOT INCLUDE ONLINE PLEDGES ON THIS FORM.
Page Total
# ____________
$ __________________
Grand Total
$________________________
page: ________ of: _______
Registered Charity # 11882 9803 RR 0003
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