Author: Killey

2015 Relay For Life of Tipton County Luminaria Form

Please Check One (Required):
o Memory (For someone who is no longer with us)
o Honor (For someone who is a cancer survivor)
Name on Luminaria:_____________________________________
Will you be decorating your luminary? o Yes o No
(Please turn in decorated bags at or before the event.)
Purchaser Information
Name: Phone Number:
Address:
City, State Zip:
Team Name (If Applicable):
Amount Enclosed (Please Check One): Suggested minimum donation $10.00
o Cash o Check $ Make Checks payable to “American Cancer Society”
Please return completed forms to:
- Any Relay For Life Team Captain - Mail to: ACS, Relay For Life of Tipton County,
www.relayforlife.org/tiptoncountyin 5635 W. 96th St., Indianapolis, IN 46278

2015 Relay For Life of Tipton County Luminaria Form

Please Check One (Required):
o Memory (For someone who is no longer with us)
o Honor (For someone who is a cancer survivor)
Name on Luminaria:_____________________________________
Will you be decorating your luminary? o Yes o No
(Please turn in decorated bags at or before the event.)
Purchaser Information
Name: Phone Number:
Address:
City, State Zip:
Team Name (If Applicable):
Amount Enclosed (Please Check One): Suggested minimum donation $10.00
o Cash o Check $ Make Checks payable to “American Cancer Society”
Please return completed forms to:
- Any Relay For Life Team Captain - Mail to: ACS, Relay For Life of Tipton County,
www.relayforlife.org/tiptoncountyin 5635 W. 96th St., Indianapolis, IN 46278