Fax Tally Sheet

Please print this form, fill it out, and fax it to 507-663-1207, or send information via email to .

Number of Students who signed the Pledge:	_____________________________________________*
School Information:
School Name:	_____________________________________________*
City:	_____________________________________________*
State:	_____________________________________________*
School Phone:	_____________________________________________
Contact Person:
First Name:	_____________________________________________
Last Name:	_____________________________________________
Phone:	_____________________________________________
Email:	_____________________________________________
	* required for national reporting purposes

Please report your tally on October 19th, 2011.
The total number of signed pledges can be seen at www.pledge.org.