Please use form for cash and cheque donations only

School
Homeroom Teacher's Name
Homeroom #
Student Name
Grade
Address
City
Postal Code
Event Date
Male
Female
Province
Telephone #
Envelope Due Back
Please print clearly and list offline donations only to ensure receipts for amounts of $20.00 and over are issued, unless otherwise specified. All online donations will receive
an automatic tax receipt. Please make all cheques payable to: Heart and Stroke Foundation. For online donations, print a summary sheet and include in this envelope.
Sponsor's Name
Mailing Address
City
Postal Code
Telephone #
Pledge
Mary Smith
123 Anywhere Street
My Town
My Code
(000) 123-4567
$15.00
Collected
Receipt
Issued*
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ue donations only
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Please use fo
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Shaded area for office use only
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MAKE ALL CHEQUES PAYABLE TO THE HEART AND STROKE FOUNDATION.
TOTAL ONLINE PLEDGES
(INCLUDE your Online Donation
Summary Sheet in this envelope)
TOTAL OFFINE COLLECTED
(INCLUDE all cash and
cheques in this envelope)
TOTAL AMOUNT
$
ENCLOSED
FUNDRAISING
GRAND TOTAL
WAIVER — PLEASE READ AND SIGN
ACKNOWLEDGEMENT AND AGREEMENT TO ACCEPT RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY POLICY OF HEART AND STROKE FOUNDATION
I hereby ACKNOWLEDGE that I have READ AND DO ACCEPT THE TERMS AND CONDITIONS set out in the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY POLICY of THE HEART AND STROKE FOUNDATION (the “Waiver and
Release Policy”) as published on the Heart and Stroke Foundation website www.heartandstroke.ca in CONSIDERATION of being permitted, or any minor (under the age of 18) under my care being permitted, to participate in or attend the event (more particularly
described in the entry form). I further ACKNOWLEDGE that I UNDERSTAND and ACCEPT that the terms and conditions set out in the Waiver and Release Policy LIMIT AND AFFECT MY LEGAL RIGHTS, including my right to sue in negligence, and freely agree to the
terms and conditions set out in the Waiver and Release Policy.
Dated at
Name of Participant
this
day of
Signature of Guardian
, 20
.