Total Donation $ ____________ ____

Check or ____ Credit Card    ____ AMEX   ____ VISA   ____ MC        

I authorized $___________ to be charged                                                                                    

COMPANY NAME ________________________________________ CONTACT____________________________________

BILLING ADDRESS, City, Zip
_____________________________________________________________________________
(Print Clearly)

BILLING PHONE ____________________________________

EMAIL ____________________________________________
(Print Clearly)

Card # ________________________________________________
Ex Date _____________
Security Code______________

Name as it appears on Card_________________________________________________________________
(Print Clearly)                              

Mail form to:
Kids Beating Cancer,
615 E Princeton St, Suite 400,
Orlando, FL   32803 FAX (407) 894-7689                                        
For more information call: (407) 894-2888 or www.kidsbeatingcancer.com