SPINAL CORD INJURY ASSOCIATION OF ILLINOIS

1032 S. La Grange Road, La Grange, IL 60525
Ph: 708-352-6223 Fax: 708-352-9065 E-Mail:SCIinjury@aol.com

COMMITMENT FORM FOR LATE MARATHON ENTRY

I, _____________________________________________, understand the value and
importance of acquiring registration in the October 12, 2008 Bank of America Chicago
Marathon via the Spinal Cord Injury Association of Illinois (SCIA).

I agree that if SCIA provides late entry, I will immediately pay $160 which includes the
marathon registration fee and the first installment of the funds I am raising or donating to
the Spinal Cord Injury Association of Illinois. I agree to raise a minimum total of $600
to help support the association’s services.

I understand that my credit card will be charged with monthly installments of $110 if
contributions are not remitted in my name. Charges will be made starting in May and
ending in September.

#______________________________________________ Exp.___________________

MC, V, Dis. Am Ex. V-Code:________________

_______________________________________________________________________
Signature Date

Name Printed____________________________________________________________

Address________________________________________________________________

City, State, Zip___________________________________________________________

Phone_____________________________________Work:________________________

Cell:______________________________________Fax:__________________________

E-mail__________________________________________________________________

_______________________________________________________________________
Witness Signature Date

(Witness) Name Printed:____________________________________________________

_______________________________________________________________________
Mercedes Rauen, SCIA Executive Director Date