!

! !

5th Annual Maine Walks with Haiti - Donation Form May 31, 2014
Walker/Runner Name: Team Name (if applicable):
I am taking part in Maine Walks with Haiti on May 31st, a 4-mile walk/run around the Back Cove in Portland. I am participating to support the efforts of Konbit Sante, a Maine-based organization that works in Haiti to improve health care. Please support this great cause and me by making a donation. For you to receive a record of your tax-deductible contribution, please include your address and/or e-mail. ** Please make checks payable to Konbit Sante, and write Walk in the memo line. **

NAME
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

ADDRESS
! ! ! ! ! ! ! ! ! !

E-MAIL
! ! ! ! ! ! ! ! ! !

Like to be added to email list? Y/N

Donation Amount

! ! ! ! ! ! ! ! ! !

Submit this form and donations on the day of the walk or mail to Konbit Sante, P.O. Box 11281, Portland, ME 04104.

www.mainewalkswithhaiti.org