ORDER FORM RELAY FOR LIFE LUMINARIA North Worcester County May 12, 2017 Frontier Town Campground Rt. 611, Ocean City, MD The American Cancer Society Relay For Life is an overnight celebration of life dedicated to present and former cancer patients, their families and friends. Relay For Life raises money for the American Cancer Society while raising awareness that cancer can and will be beaten. Luminaria that have been purchased through donations will line the track. At sundown, all luminaria will be lit in memory of or in honor of loved ones and friends who have had cancer. Each luminaria will have the loved one's/friend's name on it. You do not need to be present or a participant in the Relay to take part in this ceremony. But everyone is invited to attend and to light their luminaria candles. It's the most powerful and moving part of the Relay! Please join us in the fight against cancer! ----------------------------------------------------------------------------------------------- Donor’s Name: _____________________________________________ Phone # ( )___________________ Email: _____________________ Credit this/these luminaria to:__________________________ on Relay Team: ____________________ (individual) (team) Total Number of: Tiki Torches ____________ Luminaria bags_________ Caregiver bags_____________ Total amount enclosed: _________________ Check Cash (Credit Card orders may be placed online at the website below, by clicking on the “Luminaria” square.) ------------------------------------------------------------------------------------------------------------------------------------------------ Send this form with your contribution to : 1315 Mt Hermon Rd, Salisbury, MD 21804 For more information contact: Theresa Laviola theresalaviola@signatureworldwide.com or Jessie Parsons jessie_wolfe@Hotmail.com or Jill Elliott jelliott29@gmail.com (410)430-8131 www.relayforlife.org/northworcestermd Please light a candle in memory of or in honor of my loved one who has had cancer. I understand that the proceeds will benefit the American Cancer Society. (please print) *Required information on the reverse side of form.*

In Memory In Honor In Memory In Honor In Memory In Honor American Cancer Society RELAY FOR LIFE of North Worcester Luminaria Bags (white) – Donation of $10.00 In Memory In Honor Name on bag: ________________________ Address for Survivor to be invited to Relay Survivor Reception (optional):________________________ Address for Survivor to be invited to Relay Survivor Reception (optional): ________________________ Caregiver Bags (purple) – Donation of $10.00 In Memory In Honor Name on bag: ________________________ Address for Survivor to be invited to Relay Survivor Reception (optional):________________________ Address for Survivor to be invited to Relay Survivor Reception (optional): ________________________ Tiki Torch (Bamboo) – Donation of $25.00 In Memory In Honor Name on sign: ________________________ Name on bag: ____________________________ Address for Survivor to be invited to Relay Survivor Reception (optional):________________________ Name on bag: ________________________ Address for Survivor to be invited to Relay Survivor Reception (optional): _______________________