Donation Response Form Benefiting St. Jude Children'S Research Hospital

Donation Response Form Benefiting St. Jude Children'S Research Hospital - 2015

Please mail form and

any donation to:

Megan Urbaniak

13540 Frost Drive

Nokesville, VA 20181

Tenth Annual, August 7-8, 2015

Donation Response Form

Benefiting St. Jude Children’s Research Hospital

Contact Name ____________________________________________________________________

Company Name ___________________________________________________________________

Street Address_____________________________________________________________________

City_____________________________________________ State __________ Zip Code _________

Contact Phone Number __________________ Contact E-mail ________________________________

Website __________________________________________________________________________

In-Kind Donation Level

 Titanium Crop Donation

$2500+ retail value

 Diamond Crop Donation

$1000-$2499 retail value

 Platinum Crop Donation

$500-$999 retail value

 Gold Crop Donation

$250-499 retail value

 Silver Crop Donation

$100-$249 retail value

 Blue Crop Donation

$50-$99 retail value

 White Crop Donation

$25-$49 retail value

In order to be included in the program, all marketing materials, logos, door prize items, raffle items, and auction items MUST be received in

hand by Friday, July 10, 2015.

Please advise method of delivery/pickup: ___________________________________________________________

Item_____________________________________________________________________________________

Description________________________________________________________________________________

Value ___________________

Donation Response Form Benefiting St. Jude Children'S Research Hospital - 2015