Dedicate a Day

Online dedications will be featured on the Web site for 7 days, including your special day. Allow 5 days for your online dedication to be posted. Allow 3 weeks for receipt of a certificate.

$100+ Publish an online tribute [up to 40 words and a photo] on our Calendar of Hope.

$250+ Plus, receive a certificate suitable for framing featuring your dedication and photo.

Dedication Information

I would like to dedicate: *

a day on the Calendar of Hope ($100)

a day on the Calendar of Hope and a receive a certificate ($250)

This dedication is: *

in honor of

in memory of

I am dedicating this date: *

Occasion / Wording for Dedication: *

40 characters maximum please.

List Gift as From: *

40 characters maximum please.

Photograph:

Attach an optional photograph for use on the web site, and on your certificate (.jpg or .png less than 2MB please).

Donor Information

Please provide us with your contact information, as it appears on your credit card statement. If you wish to provide a separate notification address, you can do so further down this form.

Your First Name: *

Your Last Name: *

Your Email: *

Email Interest:

Yes, I would like to receive relevant email news, events, and updates from AA&MDSIF.

Street Address: *

Address Additional:

City: *

State / Province: *

ZIP / Postal Code: *

Country:

Phone Number: *

Payment Information

Credit Card Number: *

Please enter your Visa or Mastercard number.

Card Expiration Month: *

Card Expiration Year: *

Credit Card Security Code (CVV): *

Additional Information

In order to keep you informed with relevant news, events, and updates, we ask that you provide us with this optional information.

I am a:

Bone marrow failure disease:

If "other", please specify:

Dedication Notification

First Name:

Last Name:

Street Address:

City:

State / Province:

ZIP / Postal Code:

Country:

Originally published on 07/12/2011 - 6:16pm. Last updated on Fri, 07/15/2011 - 12:00pm.

Dedicate a Day

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