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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)