Relay For Life of Calhoun County 2010 Luminaria Form


(Please Print Clearly And Be Certain To Complete All Information)

Donors Name _____________________________________________________

Address _________________________________________________________

City ____________________________ State _____________ Zip _______

Phone ________(in case we have questions about about the names you listed)

In Memory of: 
________________________________   ______________________________

________________________________   ______________________________

In Honor Of:  
________________________________   ______________________________

________________________________   ______________________________

In Appreciation Of:
________________________________   ______________________________

________________________________   ______________________________

$5 Suggested Donation Per Luminaria
 
Amount Enclosed $____________ #Of Luminaria____________

Make checks payable to: American Cancer Society

Return this form to a Relay For Life Member or  mail to:


Judy Powell
Relay For Life Luminaria
PO Box 215
Grantsville, WV 26147