Fields marked * require an entry.

ITEM DONATION

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

Notes:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

What photo or image would you like for us to use for your donation?

How can we receive your gift certificate or item?

Is this item towards a "High School Chapter Live Package"? If so, please select the High School:

Is this a donation towards "Dessert Dash"? We are looking for a purchased dessert $30 or more:

Yes

No

Is this donation towards "Wine Cellar"? We are looking for a value of $50 or more:

Yes

No

Name of Solicitor:

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*