Honor or
Remember a loved one at the Richmond County Relay for Life
Candle lighting
ceremony to be held at approximately
9:00 on
May 19th, 2006 at Richmond Senior High School
Please Check
All that Apply.
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YES! Enclosed is my contribution for the Luminary Ceremony |
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I would like the luminaries in
honor of:
_______________________________________________________ _______________________________________________________ _______________________________________________________ |
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I would like the luminaries in
memory of:
_______________________________________________________ _______________________________________________________ _______________________________________________________ |
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I am a Cancer Survivor |
Name__________________________________________________
Address________________________________________________
City, State, Zip___________________________________________
Day Phone ( )_____________________________________
Evening Phone
(
)__________________________________
Please handle my payment for my/our order(s) as follows:
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Enclosed is my check made payable to the American Cancer Society. |
[ ] Visa [ ] Mastercard [ ] American Express
Card#_____________________________ Expiration Date ______________
Signature________________________________________________________
Day Phone (
)___________________________________
IN CASE WE NEED TO CONTACT
YOU