Download Butterflies Will Be Held Under Name Below

I would like to reserve _______ Butterflies
($10 each)
$_____________
For the event being held on: (please check
one of the below locations)
_____Sunday, June 23 at Jaycee Park in
Carthage at 2pm
_____Sunday, July 21 at Lowry Park in
Pittsfield at 2pm
_____Sunday, July 28 at Fry Park in
Carrollton at 2pm
_____Sunday, August 4 at Lower Moorman
Park in Quincy at 2pm
Butterflies will be held under name below:
Your name:
Address:
City/State/Zip:
Phone:
Number of Attending Adults: Number of
Attending Children:
Please print clearly:
1.
My gift is in honor of:
T-Shirt: Yes/No Size:
2.
My gift is in honor of:
T-Shirt: Yes/No Size:
3.
My gift is in honor of:
T-Shirt: Yes/No Size:
Mail donation with form to:
Blessing Hospice & Palliative Care
Attn: Maureen Hill
PO Box 7005
Quincy, IL 62305
4.
My gift is in honor of:
T-Shirt: Yes/No Size:
5.
My gift is in honor of:
T-Shirt: Yes/No Size:
Proceeds to benefit:
6.
My gift is in honor of:
T-Shirt: Yes/No Size:
I would like to support the work of Blessing
Hospice with an additional contribution of:
$_____________
Total Enclosed:
$_____________
Sponsors include:
Carthage: Hancock County Health
Department, Hancock Journal-Pilot,
KHQA-TV
Pittsfield: Illini Community Hospital,
WBBA Radio, KHQA-TV
Carrollton: Michelle Cordes Photography,
WJBM Radio, Bray Drug Store, Alfonso’s
Pizza
Quincy: The Alzheimer’s Association,
C.Yellow Photography, Hansen-Spear
Funeral Home, Olson Flooring, William
Siebers Elder Law Attorney, CareLink,
Bickford Assisted Living & Memory Care,
North Adams Dental, North Adams Home,
KHQA-TV, Staradio, Duker & Haugh
Funeral Home
T-Shirt Sizes (one shirt per butterfly ordered)
Adult: Small, Medium, Large, 1XLarge, 2X Large
Child: Small, Medium, Large
Payment Options
Check payable to Blessing Hospice
MC
Visa
Discover
Credit Card
Am Ex
Name on card
Credit Card #
Signature
Exp. Date
3-digit security code
(from back of card)