A Christmas To Cure Cancer Donation Form

Directions:
  1. Provide the address you wish to have your free gifts mailed to.
  2. Calculate your order, including Shipping & Handling using the table below.
  3. Choose your donation.
  4. Choose your charity.
  5. If paying by check, make checks payable to "A Christmas To Cure Cancer".
  6. Mail your order to:
    A Christmas To Cure Cancer
    5226 Columbine Ct.
    Columbus, OH 43230

Name: ____________________________________________________________
Address 1: ____________________________________________________________
Address 2: ____________________________________________________________
City: __________________________ State: ______ Zip: _____________
Phone: __________________________ E-Mail: __________________________

Item Description Donation Quantity Total
Combination Heather Pick CDs, "Circle of Support" & "A Christmas To Cure Cancer 3" with "Santa Baby"
(You may request this gift for every $25 donated)		 $25.00    
Please send me "A Christmas To Cure Cancer 4" as a free gift for my donation of $15.
(You may request one CD for every $15 donated)		 $15.00    
Please send me Sean Carney's CD, "Blues For A Cure" as a free gift for my donation of $15.
(You may request one CD for every $15 donated)		 $15.00    
Please send meSean Carney's CD, "Blues For A Cure Christmas" as a free gift for my donation of $15.
(You may request one CD for every $15 donated)		 $15.00    
Please send me Heather Pick's CD, "Circle of Support" as a free gift for my donation of $15.
(You may request one CD for every $15 donated)		 $15.00    
Please send me Kelly Delaveris' CD, "My Christmas Gift" as a free gift for my donation of $15.
(You may request one CD for every $15 donated) 		$15.00    
Please send me "A Christmas To Cure Cancer 3 " as a free gift for my donation of $15
(You may request one CD for every $15 donated) 		$15.00    
Please send me "A Christmas To Cure Cancer 2" as a free gift for my donation of $15
(You may request one CD for every $15 donated) 		$15.00    
Please send me "A Christmas To Cure Cancer" as a free gift for my donation of $15
(You may request one CD for every $15 donated) 		$15.00    
Please send me "A Christmas To Cure Cancer T-Shirt" as a free gift for my donation of $20
Medium Large X-Large XX-Large
(You may request one T-Shirt for every $20 donated) 		$20.00    
Please send me "A Coins To Cure Cancer Piggy Bank" as a free gift for my donation of $15
(You may request one "Piggy Bank" for every $15 donated) 		$15.00    
Charitable Donation      
Shipping Charges, Number of Items and Cost:
CD's 1 for $3.00 2 for $4.00 3 for $5.00 4 for $6.00 5 for $7.00
Shirts 1 for $3.00 2 for $5.00 3 for $7.00 4 for $9.00 5 for $11.00
Vidoes 1 for $3.00 2 for $5.00 3 for $7.00 4 for $9.00 5 for $11.00
Piggy Banks 1 for $3.00 2 for $5.00 3 for $7.00 4 for $9.00 5 for $11.00
*More than 5 items of any category, contact us at (614) 906-4700 or orders@achristmastocurecancer.org for Shipping prices.
  Shipping & Handling:
$ ______________
  Grand Total: $ ______________
Choose a Charity:
A Christmas To Cure Cancer
To help us cover costs of CD duplication, every $1 brings $15 in benefit towards cancer research.
The James Cancer Hospital and Solove Research Institute - Columbus, OH
American Cancer Society - Ohio Division
Ohio Cancer Research Associates - Columbus, OH
Cancer Research and Prevention Foundation - Alexandria, VA
Duke Comprehensive Cancer Center - Durham, NC
The Burnham Institute - La Jolla, CA
University of Colorado Cancer Center - Aurora, CO
University of Iowa Holden Comprehensive Cancer Center - Iowa City, IA

Thank you for your donation!