Lights of Love

Person Giving the Gift

Title:

First Name:

Middle Initial:

Last Name:

Address:

City

State

Zip

Phone

Email

Name(s) as would appear on card:

Person to be Honored or Memorialized

Type of tribute:

Title:

Name to be honored / memorialized:

Person to be Notified

Title:

First Name:

Middle Initial:

Last Name:

Address:

City

State

Zip

Donation Information

If your employer has a donation matching program, please enter your employer's name here