Miles for Miracles 5k
Hosted by the Tummers Family
Participant Name
Address
City, Province
PC
Phone Number
Email Address
Please print clearly. Mount Sinai Hospital Foundation cannot guarantee a tax receipt if information is not complete and clear.
Sponsor's Name and Contact Information
Name:
 Cash
#:
Street Address:
City:
Phone:
Prov:
PC:
Prov:
PC:
Name:
Prov:
PC:
Name:
Prov:
PC:
Name:
Prov:
PC:
Name:
Prov:
PC:
Name:
Prov:
Email:
$
 Cheque
 Credit Card
$
 Cheque
 Credit Card
$
Expiry Date:
 Cash
#:
Street Address:
Phone:
 Credit Card
Name on Card:
Email:
City:
 Cheque
Expiry Date:
 Cash
#:
Street Address:
Phone:
$
Name on Card:
Email:
City:
 Credit Card
Expiry Date:
 Cash
#:
Street Address:
Phone:
 Cheque
Name on Card:
Email:
City:
$
Expiry Date:
 Cash
#:
Street Address:
Phone:
 Credit Card
Name on Card:
Email:
City:
 Cheque
Expiry Date:
 Cash
#:
Street Address:
Phone:
$
Name on Card:
Email:
City:
 Credit Card
Expiry Date:
 Cash
#:
Street Address:
City:
 Cheque
Amount
Name on Card:
Email:
Name:
Phone:
Payment Method
PC:
 Cheque
 Credit Card
$
Expiry Date:
Name on Card:
TOTAL DONATIONS COLLECTED $
Please make cheques payable to Mount Sinai Hospital Foundation of Toronto.
DONATIONS MAY BE MAILED or DELIVERED TO:
Mount Sinai Hospital Foundation
1001-522 University Ave., Toronto, ON, M5G 1W7 Attention: Taline Artinian (Please do not mail cash)
Privacy Note: Mount Sinai Hospital Foundation may retain this information so that we may contact you periodically to provide information about health and wellness, Hospital updates and events, and fundraising and
volunteer opportunities that support the work of Mount Sinai Hospital.
Mount Sinai Hospital Foundation Charitable Business No. 11904 8106 RR001