| Supporter $35 - 249 | |
| Sustainer $250 - 999 | |
| Benefactor $1000+ | |
| Membership Amount $ | |
| Name 1: | |
| Name 2: | |
| Phone | |
| Email: | |
| Mailing Address: | |
| City/State/Zip: | |
| Country: | |
| Send me a T-shirt! I am joining for $250 or more. Choose size: | S M L XL |
| I prefer to make my
donation anonymously. |
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| I am paying by credit card. |
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| I am sending a check. |
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| My donation will |
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| Employer: | |
| Employer Address: | |
| City/State/Zip: | |
| I'd like to discuss a
planned gift, please contact me. |
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| In Memory or Honor of: |
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Please send this form, along with your check to: Kokolulu Farm and Cancer Retreats Inc. P.O. Box 340 Hawi, HI 96719 Questions? Please contact us: 808.889.9893 |