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7th Annual CMH Foundation & Dr. Russell Dohner Golf Tournament Team Application Form

Our 7 annual golf tournament is scheduled for Friday, June 10, 2011 at the Scripps Park Golf Course in Rushville. * (Rain date is scheduled for Friday June 17, 2011). Schedule:


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Tee off at 12:00 noon. Dinner and awards at 4:30 p.m. Entry fee is $60 per person, which includes a brown bag lunch, green and cart fees, a shot at prizes on various holes, and cash prizes for top men's, women's, and mixed teams. Make check payable to: CMH Foundation Deadline for application is Friday, June 3rd . By pre-registering, you help avoid long lines at the check-in desk.

Fill in the information below and send it with your entry fees to: Becky Koch CMH Golf Tournament 238 S. Congress St. Rushville, IL 62681 Please print clearly Name of Team Captain: Address: City, State, Zip: Email address: Name of Player #2: Name of Player #3: Name of Player #4: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

Culbertson Memorial Hospital Foundation & Dr. Russell Dohner th 7 Annual Golf Tournament Friday, June 10, 2011 Scripps Park Golf Course Tee off at 12:00 P.M. Dinner & Awards at 4:30 P.M. All Proceeds will be used to purchase new medical equipment for our Emergency Room Department.

Levels of Participation: (please check one) ______ Signature Sponsor--$2000

Signature Sponsor will receive special recognition in the program and free entry for one team of players.

______ Ace Sponsor--$1000

Ace Sponsor will receive mention in the program and free entry for one team of players.

______ Eagle Sponsor--$500

Eagle Sponsor will receive business name listed in the program and free entry for two players.

_______ Birdie Sponsor--$300

Birdie Sponsor will receive business name listed in the program and free entry for one player.

_______ Hole Sponsor--$150

Hole Sponsor will receive their business name on a flag on one tee.

_______ Prize or Cash Donors

The Golf Tournament Committee welcomes prizes or cash to be used as prizes & giveaways to participating players. THANK YOU IN ADVANCE FOR YOUR PARTICIPATION --------------------------------------------------------------------------------------------------------------

YES, I/We would like to participate in the CMH and Dr. Russell Dohner Golf Tournament as a Sponsor/Donor as indicated above. My/our check for $____________ is enclosed. Please acknowledge: Name: ________________________________ Address: ______________________________ Email address: _________________________ Company: _____________________________ City/State/Zip___________________________

Return form and check to:

Becky Koch CMH Foundation 238 South Congress Street Rushville, IL 62681


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