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Project Discovery Annual 3K Walk

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Name & Address of Person Making Payment

First Name*: Last Name*: Suffix:(MD, Sr., etc)
Address*:     Apt. No.:
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Daytime Phone No.*:   -     Ext.:
Evening Phone No.*:   -     Ext.:
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Payment Information

Adult Walker - $20 per person
with fundraising goal of $100
NUMBER:
$
Student Walker - $5 per K-12 student
with fundraising goal of $50
NUMBER:
$
Each walker will receive a free t-shirt and continental breakfast. Please specify the quantity of each t-shirt size below. The total number of t-shirts should be no more than the total number of walkers.

ADULT M

ADULT L

ADULT XL

ADULT XXL

CHILD L (10-12)
NAMES OF PERSONS PARTICIPATING:

Seperate names with a comma.

I AM FULFILLING A PLEDGE!

PLEASE SELECT THE PERSON WHO SOLICITED THE PLEDGE:


I would like to make a tax deductible
donation to support the Project Discovery-Alexandria
Program at the Department of Human Services.

$
T O T A L :
$

Bank Information

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Bank Account Number:
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Select Account Type: Checking      Savings

I understand that I enter this event at my own risk and I release from all liability and hold harmless Project Discovery and the City of Alexandria and any and all agents associated with them. All contributions are tax deductible to the extent allowed by the law. The City of Alexandria adheres to state and federal privacy laws to protect customer information. All payment information will be treated as confidential, and will only be shared with third parties to the extent required to complete the transaction, to collect a debt, or as otherwise required by law. This transaction is also subject to to the City of Alexandria's web site Legal Notices. For more information about the eChecks service, please contact the City of Alexandria Treasury Division, 301 King Street, Suite 1510, Alexandria, VA 22314, 703.746.3902,payments@alexandriava.gov.

YES, I understand and agree to the above terms. Please submit my payment.
NO, please cancel this payment.