American Cancer Society

Mountain View Relay For Life

Luminaria Order Form

To Honor or Remember a Loved One

On Saturday evening, May 31, at dusk, the American Cancer Society will line the track at Cuesta Park with luminarias.  Each luminaria is lit in honor of someone who survived cancer, or in memory of someone who lost their battle.  The honorees’ names are prominently displayed on the bags.  As the Relay participants walk or run throughout the night, the luminarias remind and inspire them that the fight against cancer is about real people in their communities.  It is a moving ceremony, which pays great tribute to our friends and loved ones who have battled cancer.

The luminarias are sold for a suggested donation of $10.00 each.  If you would like a Relay Team to get credit for your luminaria purchase, please fill out the form below and mail it with your payment to the address shown at the bottom of this page.  Income from luminarias purchased before the day of the Relay will be credited to the team you indicate.  Luminarias purchased at the Relay event will count towards the Relay’s grand total, but will not count towards individual team credit.

Please Print

Team Name:          Women Physicians Ob-Gyn Medical Group    

Your Name:                                                                                                                                                          

Address:                                                                                                                                                                               

City:                                                                                          State:                      Zip:                                      

Phone:                                                                                                                                                                   

In memory of:                                                                                                                                                       

In honor of:                                                                                                                                                          

Total Number of Luminaries:                                                              Amount enclosed:                              

Please submit this form along with payment to:

American Cancer Society

747 Camden Avenue, Suite B, Campbell, CA 95008

or

drop off at the front desk of Women Physicians Ob-Gyn Medical Group

Information on this website is for educational and reference purposes only and should not be interpreted as specific medical advice.

Copyright © 2006

Women Physicians

Ob-Gyn Medical Group

650.988.7550