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PLEDGE FORM

Polar Bear Jump 2008 benefiting: March of Dimes

*Checks payable to March of Dimes ________________________________________ JUMPER'S NAME ________________________________________ ADDRESS ________________________________________ CITY STATE ZIP Sponsor Name Jane Doe Sponsor Address 1234 Manchester Rd Akron, OH 44319 _______________________________________ HOME PHONE _______________________________________ WORK OR CELL _______________________________________ ORGANIZATION IF ANY Phone 555-555-5555 Pledge: Cash or Check 25.00

You must raise $25 to jump, $100+ gets you a free T-Shirt... $500 = Awesome!

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