REGISTRATION FORM

REGISTRATION FORM
Last Name: __________________________ First Name:_______________________
Address: ____________________________ City :_____________ Province: _______
Postal Code: ___________ Phone: ______________ Email: ___________________
Registration Type: Individual
Team Team Name:_________________________
Please select: 5 KM Walk 20 KM Ride 80 KM Ride
Fundraising Goal: $_________
Tshirt size: X Small Small Medium Large X Large XX Large
Waiver:
In consideration for participation in the 2015 Volta Luso Charities (“Volta Luso”), I waive and release any
and all claims that I and/or my heirs, executors, administrators, agents, insurers, assigns and other legal
representatives have or may have against Luso Canadian Charitable Society and its administrators,
trustees, officers, directors, agents, employees, volunteers, successors, affiliates, sponsors and other
legal representatives, both present and future for any accident, injury, illness, death or other claim, in law
or equity, which may result, directly or indirectly, from my participation in Volta Luso. I permit the use of
my name, amount raised, picture and video to be used in any and all forms and types of publicity
produced in connection with Volta Luso or Luso Canadian Charitable Society including, but not limited to,
the purposes of marketing, promoting or otherwise reporting relating to Volta Luso or Luso Canadian
Charitable Society. I am physically fit to participate in Volta Luso. I have read, understand and agree with
the content of this waiver/release prior to participating in Volta Luso. If participant is under the age of
majority, I confirm I am the parent/guardian of participant and sign this waiver/release on his or her
behalf.
X___________________________________________________
Signature of Participant or Guardian (if under the age of majority)
______________
Date
Notice of Registration is mandatory by either email, fax or phone before May 29th.
Event location: 2991 Concession Road 4
Township of Adjala Tosorontio, Ontario
80 KM Ride
20 KM Ride
5 KM Walk
Registration at 8:30 am
Registration at 9:30 am
Registration at 9:30 am
Start at 9:00 am
Start at 10:00 am
Start at 10:00 am
Luso Canadian Charitable Society 2295 St. Clair Avenue West Toronto, ON M6N 1K9
lusoccs.org [email protected]
P:416-761-9761 F:416-761-9310
Charitable Registration Number: 860258649 RR0001
PLEDGE FORM
Last Name:_________________ First Name:________________ Phone:________________ Email: _______________________
Address:_______________________
City:_______________ Province: _______________ Postal Code: ________________
Please complete all fields & print clearly. All monies are due on May 31st, 2015 & are to be submitted at the event. Cheques should be made payable to Luso Canadian Charitable
Society. Tax receipts will be issued for donations over $20.00. Questions? Call 416-761-9761 or email [email protected]
Name of Sponsor
Mailing Address
Email Address
Payment
Type
Credit Card
John Smith
123 Main St. Toronto, ON M6N 1K9
[email protected]
□ Cash
□ Cheque
Tax
Receipt
Yes
Credit
Card Type
Credit Card #
(all 16 digits)
Expiry
Date
Amount
MasterCard
1234 4321 1234 4321
02/15
$100.00
□ No
□ Credit Card
□ Cash
□ Cheque
□ Credit Card
□ Cash
□ Cheque
□ Credit Card
□ Cash
□ Cheque
□ Credit Card
□ Cash
□ Cheque
□ Credit Card
□ Cash
□ Cheque
Page #____ of ____
Total this page $_____
Luso Canadian Charitable Society 2295 St. Clair Avenue West Toronto, ON M6N 1K9
lusoccs.org [email protected]
P:416-761-9761 F:416-761-9310
Charitable Registration Number: 860258649 RR0001