Kohl's Step Up for Kids Donation Form


You can fill out this form before or after printing.
* = required field
Stepper Information
Participant Name*
Team Name (if applicable)
Donation Amount*
 
Sponsor Information
First Name*
M.I.
Last Name*
Billing Address*
City, State ZIP*
,    
 
Day Phone*
Email Address*
Payment Information
Donation Total
Payment Method Check   Credit Card  Cash
 
Credit Card Type  Master Card    Visa    American Express    Discover  
Name on Credit Card 
Credit Card Number
Expiration Date
/
CVS Number
 
Signature
Date
/ /

Please return completed and signed gift form, with payment
(make checks payable to Children's Memorial Foundation), to:

Step Up For Kids
Children's Memorial Foundation
75 Remittance Drive, Suite 91287
Chicago, Illinois 60675-1287

© 2009 Children's Memorial Hospital. All rights reserved.