Gouverneur Breast Cancer Fund

Annual Breast Cancer WalkOCTOBER 2, 2021

www.gouverneurbreastcancerwalk.com

g o u v e r n e u r b r e a s t c a n c e r f u n d . c o m

Pledge Sheet 2021

Make checks payable to “Gouverneur Breast Cancer Fund.”

* All team members who are present at time of registration and have a minimum donation of $35.00 in their name will receive a t-shirt.

* First 300 walkers to register will receive a gift bag.

SPONSOR $ Amount

1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.

SUBTOTAL:

SPONSOR $ Amount

21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.36.37.38.39.40

SUBTOTAL (THIS COLUMN) FIRST COLUMN SUBTOTAL

FINAL TOTAL

ENTRY FORM — On other side.

TEAM /NAME:

Join in the fun and help your neighbors, loved ones and friends who are making a difference in the lives of those fighting breast or ovarian cancer in St. Lawrence, Jefferson, Lewis, and Franklin Counties, NY. All of the funds raised are used to assist individuals who are fighting these life-threatening diseases. Just as each cancer is different, so are each person’s needs. We are here to assist.

Thank you to all our sponsors, organizations and individuals who have made this work possible.

Gouverneur Breast Cancer FundPO Box 64Gouverneur, NY 13642

To donate by mail,send your donations and pledge sheet to:

I do hereby give Gouverneur Breast Cancer Fund, the irrevocable right to use my name, picture, portrait, or photograph in all forms and media and in all manners, including composite, for advertising, for publication or any other lawful purposes, and I waive any right to inspect or approve the finished product, including written copy, which may be created in connection therewith. In consideration of my entry, I do hereby release and forever discharge any and all rights for claims and damages, which may have and which may hereafter accrue to me against the Gouverneur Breast Cancer Fund, event sponsors and organizers for damages which may be sustained and suffered by me in connection with my association with sponsors for entry in this event.

How did you hear about us? _________________________________________________________________________________Are you a breast cancer survivor? yes no If yes... for how many years?______________ or months? _____________

Team Name _____________________________________________________________________________________________Name __________________________________________________________________________________________________Address _________________________________________________________________________________________________City ________________________________________________ State ________________ Zip __________________________

Date of Birth ____________________________________________________________________________________Email _________________________________________________________________________________________Signature ______________________________________________________________________________________Parent/Guardian Signature (if under 18) ______________________________________________________________

PLEDGE SHEET — Reverse side.

GOUVERNEUR BREAST CANCER FUND Entry Form 2021

Platinum SponsorsCasablanca RestaurantCives SteelCollins-Hammond Electrical ContractorsElizabeth Wende Breast Health CenterFABCOLiberty UtilitiesNorthern Credit UnionNorthern Tier ContractorsPrice ChopperRSI RoofingSamaritan Medical CenterSlack Chemicals Company, Inc.St. Lawrence Medi-SpaWal-Mart

Diamond Sponsors

Pink SponsorsA Plus Auto CareAll About MeAmerican Legion Auxiliary Post 65G&R Auto PartsGouverneur Elks ClubSmith Civil Engineering, PLLCSundance LeisureThe Upstate BankWise Women OB/GYN

Gold SponsorsCommunity Bank, N.A.Corning, Inc.DefelskoEmpire State MinesENI MechanicalGouverneur Dental AssociationGouverneur Savings & LoanGouverneur Teachers AssociationRM Conklin Agency, Inc.TLC Real Estate, LLCVanderbilt Mines, LLCWeekes Agency

Media Sponsors

Silver SponsorsAmerican Legion Post 65Bush FuelsCarthage Area HospitalCheney TiresClipper InnDr. Nicholas Gardner, DDSGreen Funeral HomesJenne & Carr Insurance AgencyJreck SubsM&M Heating & Air ConditioningMacFadden Dier Leonard InsuranceMort Backus & SonsMullin’s RestaurantNorthern GlassNorth Country Insurance ProfessionalsPistolesi RentalsRBC Wealth ManagementRiver HospitalSeacomm Federal Credit UnionSilver Leaf Dinerwww.gouverneurbreastcancerwalk.com

Elite Sponsors