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Luminary Form 2010
- 1. Light the Night With Luminaries Montgomery County Relay for Life East Montgomery High School th st April 30 May 1 6pm 6am There will be hundreds of candles lighting the night at East Montgomery High School Track each one a tribute to a cancer patient. Candles displaying the names of all those being remembered and honored will be lining the track after sunset on Friday, April 30th, 2010. This will be a meaningful and inspirational ceremony and we would like to invite you to participate in this years event by having a candle lit in Memory of a loved one or in Honor of a survivor. Survivor: _____________________________________________ Given by: ____________________________________________ In Honor of a Survivor Each luminary requires a $5 donation Phone Number: _______________________________________ or 3/$10. Acknowledgment Card to be sent? Yes or No (Please Circle) I would like a candle lit in honor of each Send Acknowledgment To: of the following survivors: Name:_____________________________________________ Address: ____________________________________________ City: ________________________ State: ____ Zip: ________ Survivor: _____________________________________________ Survivor: ____________________________________________ Given by: ____________________________________________ Given by: ____________________________________________ Phone Number: _______________________________________ Phone Number: _______________________________________ Acknowledgment Card to be sent? Yes or No (Please Circle) Acknowledgment Card to be sent? Yes or No (Please Circle) Send Acknowledgment To: Send Acknowledgment To: Name:_____________________________________________ Name:_____________________________________________ Address: ____________________________________________ Address: ____________________________________________ City: ________________________ State: ____ Zip: ________ City: ________________________ State: ____ Zip: ________ In Memory of_________________________________________ Given by: ____________________________________________ In Memory of a Loved One Each luminary requires a $5 donation Phone Number: _______________________________________ or 3/$10. Acknowledgment Card to be sent? Yes or No (Please Circle) I would like a candle lit in memory of Send Acknowledgment To: each of the following people: Name:_____________________________________________ Address: ____________________________________________ City: ________________________ State: ____ Zip: ________ In Memory of_________________________________________ In Memory of_________________________________________ Given by:____________________________________________ Given by: ____________________________________________ Phone Number: _______________________________________ Phone Number: _______________________________________ Acknowledgment Card to be sent? Yes or No (Please Circle) Acknowledgment Card to be sent? Yes or No (Please Circle) Send Acknowledgment To: Send Acknowledgment To: Name:_____________________________________________ Name:_____________________________________________ Address: ____________________________________________ Address: ____________________________________________ City: ________________________ State: ____ Zip: ________ City: ________________________ State: ____ Zip: ________ Make checks payable to: American Cancer Society If you would like your donation credited to a particular Relay team, please note that here. MAIL TO: JIM RUSSELL-OWEN 1011 PAGE STREET TROY, NC 27371