donation

Jiggin 4 a Cure

The Kelly-Oster School of Irish Dance Relay Team

Yes, I would like to light the way to a cure!

Name______________________________________

Address_____________________________________

Registration Fee: $10.00 due to Siobhan Trippodo by May 15th.

I would like to be part of the KKO Relay Team. Please sign me up to walk 1 hour.

Donation Amounts:

I would like to donate $5.00 and add a name to our school team T-shirt to honor a loved one who has been affected by this illness. Our T-shirts will be in memory of those who have lost their battle with cancer & honor those who are fighting or have beaten cancer.

I would like to donate $10.00 to luminate a candle

Please dedicate a candle to the following person:

In honor / memory of______________________________________

I would like to donate $20.00 and recieve a 2008 KKO Relay for Life T-shirt

T-shirt Size: (circle one) Youth S Youth M Youth L Adult S Adult M Adult L Adult EXL

Please dedicate & add the name of the following person to the T-shirt

In honor / memory of______________________________________

I would like to donate $25.00 to luminate 3 candles

Please dedicate a candle to the following person:

In honor / memory of______________________________________

I would like to donate $50.00

and add the name of my business or organitation to the 2008 KKO T-Shirt

Businness Name______________________________________

I would like to make a donation of $__________ __.

Please make checks payable to the American Cancer Society and mail to by 5/15/2006.

Siobhan Trippodo: 15 Amazon Road, Carmel, NY 10512

Your donation is tax-deductible. If you cannot use your check for a receipt and would like a receipt sent to you please check here [ ].

Thank you!