Send to: David Johnson; 3021 West River Road; Grand Island, NY 14072  USA

Or send email to: girotary@hotmail.com

Name:         ______________________________________________________________________________

Address:____________________________________________________________________________

Address 2:___________________________________________________________________________

City:         ___________________________________________         State/Province:_____

Zip/Mail Code:_________________  Country:___________

Phone: ______________________   Fax: _____________________  Cell: _______________________

E-mail:         _____________________________________________________________________________

Donation: _____________     (makes checks payable to: Rotary Club of Grand Island—Walk)

SPONSOR LIST:
NAME                           ADDRESS/CITY/STATE/ZIP              DONATION          PAID

Name:

Address 1:

Address 2:

City: State/Provence: Zip/Postal Code

Donation:

Send check to: David Johnson, 3021 W. River Rd., Grand Island, NY 14072-1559, USA

(Payable to Rotary Club of Grand Island – Walk)

Pay in cash at the walk:

How many miles?