Help our Garden Grow:  Credit Card Donation Form

PLEASE SELECT ALL OF THE FOLLOWING CATEGORIES WHICH APPLY TO YOUR DONATION(S):

     BRICK ORDER ($100 per brick): 

           You may purchase a brick in honor of or in memory of a woman who has been/was diagnosed with a
        gynecologic cancer.  Gynecologic cancers include malignancies of the ovary, endometrium, uterus, cervix,
        vulva, and vagina. To order one or more bricks, fill in the proposed inscription(s) below exactly as you
        want your brick to appear.  Fill in multiple forms for multiple bricks.  If you do not know a woman affected
        by a gynecologic cancer, please consider donating a brick in honor of our organization.

           SAMPLE INSCRIPTIONS:    
                     
                       IN HONOR OF                   IN HONOR OF                 IN MEMORY OF               IN MEMORY OF             IN HONOR OF
                         JANE LILY                          JANE LILY                         JANE LILY                         JANE LILY            LILIES OF THE VALLEY
                                                                                BY                                                                              1925 - 1998                  BY JOHN SMITH
                                                                       JOHN LILY

          Type inscription below. Text limited to 4 lines of text, 21 characters (letters, numbers, spaces, characters) per line. 
         THREE LINES OF TEXT WITH A MAXIMUM OF 18 CHARACTERS IS RECOMMENDED. Upper and lower case may be used.
         UPPER  CASE IS RECOMMENDED.   All inscriptions are subject to the approval of the Lilies of the Valley Board of Directors.   
        

         The individual whose name appears on the brick was diagnosed with  cancer.  
 

CORPORATE AND INDIVIDUAL SPONSORS (Amounts vary as listed below)

         Lilies of the Valley welcomes individual and corporate sponsors for this project. Sponsorships will be                                                               
         recognized on our “Walk of Honor.”

         Sponsorship levels:  Platinum $ 5000 and above
                                             Gold         $ 2500 to $ 4999
                                             Silver       $ 1500 to $ 2499
                                             Bronze     $ 500 to $ 1499
                                             Teal          $ 250 to $499

          Please complete the following information if you would like to participate as a sponsor. 

          NAME
                       (Name of organization or individual as you would like it to appear on “Walk of Honor.”)

          CONTACT PERSON

          AMOUNT OF SPONSORSHIP  

          Please read and check the following:
         I have double checked the proposed inscription as listed above under “Name.”  I understand it will appear EXACTLY as I  have written.


 TOTAL COST OF ABOVE ITEM(S):
           Please total the cost of your donation(s).  Please add a $3 credit card convenience fee to your total and enter the total amount in the
           box below.
               $ **Write down or remember this total amount to enter in the next page.**
 

CONTACT INFORMATION:

Name
Title
Organization
Street Address
City
State
Zip
Phone
E-mail


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