Festival of Lights 2017 - Schuyler Hospital

Name of individual or group donating to Festival of Lights as you want it to appear on the wreath*

Honoree #1*

First Last

Check one*

In Memory of
In Honor of

Honoree #2

First Last

Check one

In Memory of
In Honor of

Honoree #3

First Last

Check one

In Memory of
In Honor of

Honoree #4

First Last

Check one

In Memory of
In Honor of

Honoree #5

First Last

Check one

In Memory of
In Honor of

Honoree #6

First Last

Check one

In Memory of
In Honor of

Honoree #7

First Last

Check one

In Memory of
In Honor of

Honoree #8

First Last

Check one

In Memory of
In Honor of

Total Honorees*

Price: $5.00

Total of $5 per each honoree

Total

$0.00

Billing Information

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone