Second Annual DBSA Walk for Mental Health Awareness

Saturday, May 19, 2012 at 11:00 am

Saratoga Spa State Park
Walker Registration and Sponsorship Form
The DBSA 5K Walk for Mental Health Awareness is also a fundraiser for the DBSA of Saratoga County. You
can help us help others with a tax-deductible donation to the Depression and Bipolar Support Alliance-Saratoga
County. All proceeds go to funding our member service activities, including support group meetings, special
events, training, advocacy, promoting research, advertising, and other member services. DBSA-Saratoga
County is a non-profit corporation in accordance with the provisions of the I.R.S. Code, Section 501(c)(3). Our
EIN number is 90-0592244
TEAMS AND SPONSORS: You are welcomed to assemble a team and collect donations from your friends and
family members. Walkers that collect at least $20.00 dollars in donations will receive a 2012 DBSA Walk for
Mental Health Awareness t-shirt. Teams are also encouraged to create their own shirt.
Walkers Name: _______________________________________________________________________________
Walkers Address:________________________________________City:_______________________State_______
Walkers Phone:_______________________________ Email:__________________________________________
I am walking with a team:

Yes

No

If yes, my team is: ____________________________________________

SPONSORs FULL NAME

DONATION AMOUNT

1)_________________________________________________________

$___________

2)_________________________________________________________

$___________

3)_________________________________________________________

$___________

4)__________________________________________________________

$___________

5)__________________________________________________________

$___________

SUBTOTAL: $___________
More sponsors and donations are listed on the back of this form:

Yes

No

DONATIONS COLLECTED: Front $________ + Back $_________ = TOTAL:__________

I collected a total of $20.00 or more in donations. I would like a T-Shirt. Yes
My shirt size is ________ (Adult sizes: S, M, L, XL, 2X).
Please make your check payable to DBSA-Saratoga County and mail to:
DBSA-Saratoga County
ATTN: Chris Jasikoff
608 Acland Blvd
Ballston Spa, NY 12020

If you have any questions please call Chris Jasikoff at 518-580-1064.

Second Annual DBSA Walk for Mental Health Awareness

No

Saturday, May 19, 2012 at 11:00 am

Saratoga Spa State Park
Walkers Name: ________________________________________________
SPONSORs FULL NAME

DONATION AMOUNT

6)_________________________________________________________

$___________

7)_________________________________________________________

$___________

8)_________________________________________________________

$___________

9)__________________________________________________________

$___________

10)__________________________________________________________

$___________

11)__________________________________________________________

$___________

12)_________________________________________________________

$___________

13)_________________________________________________________

$___________

14)_________________________________________________________

$___________

15)__________________________________________________________

$___________

16)__________________________________________________________

$___________

17)__________________________________________________________

$___________

18)_________________________________________________________

$___________

19)_________________________________________________________

$___________

20)_________________________________________________________

$___________

21)__________________________________________________________

$___________

22)__________________________________________________________

$___________

23)__________________________________________________________

$___________

24)_________________________________________________________

$___________

25)__________________________________________________________

$___________

SUBTOTAL: $___________
Copy the subtotal to the front side of this form.

THANK YOU FOR YOUR SUPPORT!