(2020-2021) District 29I Diabetes Pin Order Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Each pin costs $4.00. Cash or Checks will be accepted.

If paying by check, please make checks out to the following: Lions Club District 29I Diabetes Account.

Cash and checks can be sent to:
Lion Brendan Byrne
District 29I Diabetes Chairperson
61 Husk Trail
Berkeley Springs, WV 25411

Thank you for supporting Diabetes Awareness throughout District 29I.

Email *

Name (Last, First) *

Name of Local Lions Club. *

Number of pins you want to purchase. *

Method of Payment *

Cash

Check

Product options *

I acknowledge that the pin(s) that I purchase will be released after money is received. After the money is received, all purchased pins will be delivered to the local club president to be distributed.

Required

Contact info

Please provide the following information if you need to be contacted for any reason concerning your order.

Phone number (Mobile and Home): *

Preferred contact method *

Phone

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Washington County Public Schools. Report Abuse

Forms