Butterflies

KIDNEY CHALLENGE

BUTTERFLY RELEASE ORDER FORM 2017

I would like to have a butterfly released at the Kidney Challenge Walk on Sunday, July 9, 2017 at the St. James Church Hall to commemorate:

______________________________________________________________________________________________________________________________

_____ In memory of

_____ In honor of

_____ Just because I care

 

My contact information is (please print):

Name: _______________________________________________________

Address:______________________________________________________

City:_______________________  State: ___________ Zip: _____________

 

Phone: ________________________ Email: _________________________

 

Please submit this completed form and your check contribution of $20 per butterfly to:

Southern Tier Kidney Association

P.O. Box 834

Jamestown, NY 14702

Questions? www.southerntierkidneyassoc.org

Email  kidneychallenge@yahoo.com