First Name *

Last Name *

Spouse Name *

Email *

Phone Number *

Street *

City *

State *

Choose your State Alberta ALASKA ALABAMA ARKANSAS AMERICAN SAMOA ARIZONA British Columbia CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA FEDERATED STATES OF MICRONESIA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS Manitoba MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI NORTHERN MARIANA ISLANDS MISSISSIPPI MONTANA New Brunswick NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY Newfoundland and Labrador NEW MEXICO Nova Scotia Northwest Territories NUNAVUT NEVADA NEW YORK OHIO OKLAHOMA ONTARIO OREGON PENNSYLVANIA Prince Edward Island PUERTO RICO PALAU Quebec RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA Saskatchewan TENNESSEE TEXAS UTAH VIRGINIA VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING Yukon

Zip *

Donation cause *

Select Donation Package D001 D002 D003

Amount *

Children Below 6 Years

0 1 2 3 4 5 6 7 8 9 10

Age 7-15

0 1 2 3 4 5 6 7 8 9 10

Youth 16 – 23

0 1 2 3 4 5 6 7 8 9 10

Donation Packages

Package	Description	Donation Range
D001	Royal Sponsor	$100,000+
D002	Grand Sponsor	$50,000 - $99,999
D003	Grand Donor	$25,000 - $49,999
D004	Grand Benefactor	$10,000 - $24,999
D005	Benefactor	$5,000 - $9,999
D006	Grand Patron	$2,500 - $4,999
D007	Patron	$1,000 - $2,499