Registration Form - Team - Individual - Sponsorship - Donation

1. Homburg Charity Golf Challenge 2012
In support of Make-A-Wish
Sherwood Golf & Country Club, Chester, NS
Wed. Sept 12, 2012 5991 Spring Garden Road, Suite 605, Halifax, NS B3H 1Y6
P 902-466-9474 F 902-466-0602 www.makeawish-atl.ca
Registration/Sponsorship
Please return by fax: (902) 466-0602 Or E-mail: daphne.carter@makeawish.ca
Primary Point of Contact Name:
Daytime Phone: Email:
Company: Team Captain Name:
Billing Address:
City: Prov. PC:
Team Name (if any): NOTE: Registration fee due by Wed. Sept 5th
Team Members (if known):
1. 2. 3. 4.
Participation Options: A.) Full Team (4) $1000 x ____ = $ B.) Individual Player $250 x ____ = $
C.) Sponsorship Level: =$ D.) Donations: = $ Donations are eligible for a
(available upon request) charitable tax receipt
Payment Options: A.) By Credit Card: B.) By Invoice: C.) By Cheque: (Payable to “Make-A-Wish Atlantic”)
Credit Card Type _ ___ (Visa, MC, AMEX) Card # ______________ _____________________ Exp. Date /
(Mon / Year)
Signature of Card Holder: