2nd ANNUAL CIGAR SMOKE OUT AGAINST CHILD ABUSE

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DONATION & RECORD FORM

Donated by: (PLEASE PRINT)

Name: _________________________________________________________________________________

Address: _______________________________________________________________________________

City: ____________________________ State: ______________ Zipe Code: _________________________

Phone Number: ___________________________ Email: _________________________________________

Amount: ___________________________ Visa | Mastercard | Amex | Discoer | Check |

Credit Card Number: __________________________________ Expiration Date: _______________________

Name on Card(if different from above): _________________________________________________________

 

Make Checks payable to: The Howard Phillip Center for Children and Families

Mail to the attention of: Michael Cherowitz

3420 Charow Lane

Orlando, Florida 32806

407-227-7510

mcherowitz@earthlink.net

 

Please note that Orlando Regional Healthcare Foundation will receipt you for your tax deductible
in-kind donation after receiving this form. Thank you for supporting this event and the programs
of Arnold Palmer Hospital for Children & Women.