Walkathon Registration Form

Registration starts at 09.00 AM
Sunday, September 08, 2019 - 10.00 AM

Venue: ERINDALE PARK, Mississauga ,
Areas C & D
( Mississauga Road & Dundas Street W)

Entry Fee : Ages 13 and above : $20
Below 13 : $10; Toddlers : Free

Special Offer : For those who participate in both events, we will have free food coupons for you at the walkathon

(Handi-Care Intl. will issue receipts)


Name	:

Address	:

City,Province	:

Postal code	:

Phone	:

Email Address	:

Donation Options	:	E-Transfer (Preferred method) Paypal / Credit card (2% will be charged by the CC from your donation. Please add 2% to your donation amount so the full amount will go towards the program you have selected. Thank you) Cheque

Purchase Raffle Tickets Online	:	Yes No (Raffle Prizes List)

Select ticket (The draw will take place on Sept. 8th at the Walkathon and you will be notified)	:	$100-10tkts $40-3tkts $20-1tkt

Walkathon - Registrant / Pledger	:	Yes No ( "Yes"- Registrant / "No"- Pledger)

No. of Registrant	:	No. of Adults: No. of children:

If Pledging - Who are you Pledging for ?	:

Total Amount (Raffle, Registrant, Pledge)	:	$

Comment	:

Can your name be published on our website?	:	Yes No

Registration List

NAME	Sponsor	Registrant Walkathon	Amount	No. of Adults	No. of Children
Subha Varadarajan		Yes	60	2	2
Aliya Satani			50
Vijay Bajaj		Yes	100	2
Gaibrie Stephen		Yes	25	1
Andrei Smarandache		Yes	50	2	1
Shyam Baskaran		Yes	40	2
Shyam Shankar & Gwen Hughes		Yes	160	2	2
Sandra Impey			60
Ryan Liebscher			300
Michelle White			100
Rishi Bajaj		Yes	100	2
Marlee Klaiman		Yes	20	1
Guruprasad Desai			40	2
Kousha Azimi			50
Mathu Baskaran			41
Neil Dattani		Yes	50	1
Karim Jessa			50
David Kepecs			20
Nikolaos Mamalias			110
K Badra			100
Arun Chockalingam		Yes	40	2
Stephanie Seilman		Yes	20.00	1
Christian Medved			100
Zahra Kanji		Yes	20.00	1
Zainab Najarali		Yes	20	1
Janna MacLachlan		Yes	50	1
Angelica Ng			200
Physio Connect - Advert	Yes
Prakash Bansod		Yes	50	1	1
Foundation Physio- Advert	Yes
VMS Travel- Advert	Yes
Kannan Dental- Advert	Yes
Team Works- Advert	Yes
Sanskriti- Advert	Yes	Yes		2
Shankar Vilanur- Advert	Yes
All About Kids- Advert	Yes
Alex Ghani- Advert	Yes
Amit Saini - Advertisement	Yes
MD Management- Advert	Yes
CIBC Woodgundy- Advert	Yes
Sandra Rao		Yes	20	1
Parthiban Elangovan		Yes	40	2	1
Jaikumar Chinnakonda		Yes	80	4
Dinesh Krishna		Yes	2000	2	2
Sulo Krishnamurthy		Yes	1000	1

		Total	5166	36	9