Visit online: www.dancingwithverostars.com

Company Name _________________________________________________________________________________________________

Address __________________________________________________________________________________________________________

City ____________________________________________ State _________________________ Zip Code ________________

Phone _________________________________________ E-mail _________________________________________________________

MASTERCARD VISA AMERICAN EXPRESS CHECK (enclosed)

Card Number __________________________________________________ Exp. Date ____________ Sec. Code _____________

Amount to be Charged $ ______________________ Signature ___________________________________________________________

Please return form to (and make check payable):

Indian River County Healthy Start Coalition

1555 Indian River Boulevard, Suite B241 - Vero Beach, Florida 32960 | Telephone 772-563-9118 | Fax 772-563-9125

Total Price: $______________ Please ensure to distribute funds to Dancer(s) of choice below. Counts in voting.

DR. KATyA BAIloR

$______________ $______________ $______________ $______________ $______________

$______________ $______________ $______________ $______________

Sponsorship(s) ____________________________________________________________________ | $ _________________________

No, I cannot sponsor this year, but I would like to make a donation in the amount of $ ____________________________________

to the Indian River County Healthy Start Coalition

Thank you for your support of Healthy Start Coalition, Dancing With Vero’s Stars and our partner Riverside Theatre.We are grateful for your part in helping better our children and families in having a healthier start.

$______________

This evenT benefiTs

TAMMy BuRSICK DR. GIulIANA DIAZ JoNES

2018 COMMITMENTFORM

BEN EARMAN RICHARD GIESSERT

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