JUNE 24 - FUNDRAISER REGISTRATION Dale Brain Injury Services / DBIS

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Event Address: 345 Saskatoon St. London ON - Centre for New Tomorrows/CNT
Contact us at: 519-668-0023 ext119 or Email: stacyv@daleservices.on.ca

There are many ways to support the DBIS Fundraiser. Select all that apply: *

Make a Donation: www.daleservices.on.ca

Join Walkathon at CNT on June 24 - select a preferred time to attend below

Join Virtual Zoom Event on June 24 at 11am

Buy DBIS T-Shirt!...$25 on sale at CNT on June 24 - cash only

Stop by CNT to say Hello on June 24 - select a preferred time to attend below

Be Active at Home

Be Active in My Community

Required

Choose your preferred time to attend in person on June 24 at CNT. Note: 30 spaces are available for each time slot. Choose an alternate time in the next question.

My alternate time to attend on June 24 is:

Please read and Confirm the Safety Wavier - I Agree; that at all times during the Dale Brain Injury Services Fundraiser, that my safety remains my sole responsibility and; that I am aware of the inherent risks in participating in the Dale Brain Injury Services Fundraiser and assume such risks. *

I Agree

Not Applicable

Required

Please list your name and name(s) of the people attending with you on June 24:

What is your Email?

What is your Phone Number?

Mailing Address:

How did you hear about the event? *

Friend

Social Media

Dale Services

Required

I voluntarily give my consent for photographs and video to be taken and used by Dale Brain Injury Services Inc. for the purpose of Marketing, Public Relations, Community Awareness, Fundraising and DBIS social Media. I have the right to withdraw this consent at any time. *

I Agree

No, consent is not provided

Memorial Award Introduction: To pay tribute to the memory of Jim Buffone, Dale Services is honoured to introduce the annual Memorial Award at this years fundraiser. This recognition will be received by a Client of the organization. Please nominate a Client and share how the nominee demonstrates; perseverance, kindness, inspires others to be genuine, shares smiles, is non-judgmental, contributes to others good mood and is supportive of others.

I Nominate (please include first and last name of the client below):

I nominate this client because:

Nominated By:

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