Sample Pledge Form printable pdf download

Sample Pledge Form

Pledge Form

Student’s Name: ________________________________________________________________ Grade: ______________

Street Address: ______________________________________________________ Phone: ________________________

City: ____________________________________________________________ State: ______ Zip: ________________

PLEDGE

FLAT

TOTAL

SPONSOR’S NAME

SPONSOR’S ADDRESS

SPONSOR’S PHONE

PER____

DONATION

CONTRIBUTION

Thank you for your support! Please make checks payable to Riley Hospital for Children.

Total number (books read, miles walked or rode, jumps, words spelled, etc.) completed: ____________________________

Verified by: ____________ (volunteer or teacher initials)

Total Pledge Amount Due:

$ ________________

Total Flat Donations: $ ____________

Total Amount Collected:

$ ________________

Date Received: __________________

(for office use only)

Sample Pledge Form