Loop the Loop for Kids - Pledge Form

You can fill out this form before or after printing.
* = required field
First Name*
Last Name*
Company
Address*
City, State, ZIP*
,    
Country*
 
Phone*
Email Address
 
Runner/Walker's Name*
Pledge Amount*
Pay by  Credit Card   Check  Money Order
 
Card Type Visa      Master Card     Discover     American Express
Name on Card 
Card Number
Expiration
/
 
Signature
Date
/ /

Please return completed and signed donation form, with payment
(make checks payable to Children's Memorial Foundation), to:
Loop the Loop for Kids
Children's Memorial Foundation
2300 Children's Plaza, Box #4
Chicago, IL 60614
Attn: Jamie Arquilla

If paying with credit card, you may fax this form to
Loop the Loop for Kids at 773.880.3304.

© 2008 Children's Memorial Hospital. All rights reserved.