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The Dominic Trionfo Memorial Fund * P.O. Box 1023, Middle Island, NY 11953

www.dominicmemorialfund.org

Please submit by 03/10/20. Delivery will be by early May 2020.

Name and Position of Person Ordering

Name and Position of Contact Person

School District

Contact Email Address

Contact Phone Number

Contact Address

Delivery Address

(Please include a person’s name with the delivery address. If more than one address, please email the additional information and quantity or indicate each address on a separate sheet.)

Total Number of Classroom Kits (sets of 30)*

(Each kit includes 30 activity books, 30 parent letters, and a teacher guide.) Please give breakdown below.

Grade? How many classes per grade? About how many students per class?

Please press submit after filling out this form. Any additional notes can be added below. Please contact us at info@dominicmemorialfund.org with any questions or with additional information. Thank you for being a part of our Boater and Water Safety Program!