Children taking a stand

We Took a Stand Against Childhood Cancer

This September

Name of Participating Child*

First Name Last Name

Name of Parent

First Name Last Name

Parent Email

example@example.com

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Total Amount Enclosed (if mailing in)

Brief Description of Event

SUBMIT DONATION ONLINE HERE (Skip this step if submitting via mail)

USD Description

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

*All participating children will be automatically entered to win one out of five Amazon gift cards ($25 value each). Forms with payment must be received by October 16, 2017. Winners will be announced on October 17, 2017. There will be five winners, selected at random. There is no minimum fundraising requirement to be entered, and selection will not be weighed according to fundraising success. For each gift card awarded to a TLC fundraising participant, another gift card of equal value will be donated to a child who is currently in treatment for cancer, and who lives in the Houston region where he or she may be displaced from home as a result of the tragic aftermath from Hurricane Harvey.

IMPORTANT REMINDERS:
• Personal checks must be made out to the Ty Louis Campbell Foundation.
• Cash must be converted to a bank check or money order before mailing in.
• All funds collected should be mailed to the address below within 14 days of event completion of fundraising activity ALONG WITH A COPY OF THIS FORM.
• Email any questions to info@superty.org

The Ty Louis Campbell Foundation
Take A Stand September Team

1787 Route 6
Carmel, NY 10512