Donation Guidelines
Please remember these guidelines for giving:
$10.00 for each certificate
$50.00 for one gift and up to five certificates
$100.00 for two gifts and up to five certificates
$150.00 for three gifts and up to five certificates

Important: Enter a valid e-mail address. Receipts will be sent to this address.
*E-Mail:
Honored Teacher Certificate Information
Important Note: Our automated system will use this information to print certificates. Please spell names carefully!
Teacher First Name
Teacher Last Name
Gift Choice	Choose a Gift No Gift Required T-Shirt Thermal Mug Tote Bag
T-Shirt Size	T-Shirt Size Small Medium Large X-Large XX-Large
Donation Given By:
School Name
Date Needed
Teacher #2 First Name
Teacher #2 Last Name
Gift Choice	Choose a Gift No gift T-Shirt Thermal Mug Tote Bag
T-Shirt Size	T-Shirt Size Small Medium Large X-Large XX-Large
Donation Given By:
School Name
Teacher #3 First Name
Teacher #3 Last Name
Gift Choice	Choose a Gift No Gift T-shirt Thermal Mug Tote Bag
T-Shirt Size	T-Shirt Size Small Medium Large X-Large XX-Large
Donation Given By:
School Name
Teacher #4 First Name
Teacher #4 Last Name
Gift Choice	Choose a Gift No gift T-shirt Thermal Mug Tote Bag
T-Shirt Size	T-Shirt Size Small Medium Large X-Large XX-Large
Donation Given By:
School Name
Teacher #5 First Name
Teacher #5 Last Name
GIft Choice	Choose a Gift No gift T-shirt Thermal Mug Tote Bag
T-Shirt Size	T-Shirt Size Small Medium Large X-Large XX-Large
Donation Given By
School Name
Please allow one week for delivery
Questions? Call toll free nationwide 1-866-933-CURE option 2. Or email orders@curingkidscancer.org
Donor Information
Certificates and gifts will be sent to this address
*First Name:
Middle Initial:
*Last Name:
*Address Line 1:
Address Line 2:		Apt. or Suite No.
*City:
*State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip Code:
*Phone:
Donation Information
*Donation
Silicon Bracelets	Choose Item 5 Silicon Bracelets $5.00 10 Silicon Bracelets $10.00 15 Silicon Bracelets $15.00 20 Silicon Bracelets $20.00 25 Silicon Bracelets $25.00 30 Silicon Bracelets $30.00 35 Silicon Bracelets $35.00 40 Silicon Bracelets $40.00 45 Silicon Bracelets $45.00 50 Silicon Bracelets $50.00
Sub-Total:
*Shipping	Choose Shipping Standard Shipping $4.99 Expedited Shipping $20.00
Grand Total:
Credit/Debit Card Information
*Card Number:		No dashes or spaces please
Card Brand:	Choose a Card American Express Discover Master Card Visa
*Expiration Month:	Month January February March April May June July August September October November December	From your card
*Expiration Year:	Year 2004 2005 2006 2007 2008 2009 2010 2011	From your card
*CVV2
Online Payments