THE ALEXA TAYLOR WALK-A-THON

OCTOBER 2, 2005

CHECK IN FORM

(All walkers need to turn in form by September 10, 2005)

Please make checks payable to

Meningitis Angels Heaven and Earth Bound, Inc.

and mail with form to

P O Box 448      Porter, Texas 77365

 SELF-SPONSORED                        SPONSORED

NAME:___________________________________________________________

ADDRESS:________________________________________________________

CITY:________________________________ STATE:______ ZIP:____________

PHONE#:____________________________E-MAIL:_____________________

WAIVER: I __________________ hereby waive all claims against the Meningitis Angels Heaven and Earth Bound, Inc., and event sponsors and personnel, for any injury I might suffer in this event. I attest that I am physically fit and prepared for this event. I grant full permission for event organizers to use photographs of me, and quotations from me, in legitimate accounts and promotions of this event.

____________________ ________________

Signature Date

FINANCIAL: All walkers need to turn in form by September 3, 2005 with $25.00, any and all other monies must be turned in on or before the day of walk.

CONTRIBUTION RECEIVE SIZE (please circle)

$25 Walk-A-Thon T-shirt Large, X-Large or XX- Large

$50 Walk-A-Thon Water Bottle  & T-shirt Large, X-Large or XX-Large

$100+ Walk-A-Thon Water Bottle &  T-shirt Large, X-Large or XX-Large

Money turned in on or before  9/3/05 $______

Money to be turned in on 10/2/05 $______

TOTAL MONEY RAISED $______

SPONSORS: NAME    and  DONATION Amount

_________________________ ______________

_________________________ ______________

_________________________ ______________

_________________________ ______________

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