Dysautonomia Foundation, Inc.
A non-profit organization supporting medical research 
and treatment for people with Familial Dysautonomia

 
 
7th Annual FD Cycle Tour
Tour de Foliage

Cycle Tour Jerseys - $75 each

Jerseys will be distributed at 8 AM
Sunday, September 12th, 2010
(Rain or Shine)
at Pace University, Pleasantville, NY


Photos above are 2007 jersey (red) 2008 jersey (blue) and 2009 jersey (green).
2010 Jerseys will be a similar style, in purple.


Please use this form to purchase a jersey. Jerseys are $75 dollars each and will be distributed at the event.
You will receive an email receipt for your purchase.
Please note, this purchase is not a tax deductible donation.

Please be assured that your transaction is secure and none of your credit card information will be stored in our records. Your privacy is important to us. We will not share your information with any other organization and you will not be added to any third-party mailing lists.

Once you fill out this form, you will be transferred to a secure web site
to enter your credit card details.

Jersey Type: Please select an item
Sponsor Amount: Bowler sponsorship amount
Raffle Tickets: Contribution for raffle tickets
Rider:
Enter name of rider
Total Amount: $ 
(do not type in this field)

Your First Name:  
Your Last Name:  
Mailing Address: Address 1
  Address 2
City:  
State / Zip:     
Phone Number: 10 digits only, no ( ) - symbols
eMail Address:  
Method of payment: 


Click the button above only once.


Sample Jersey Design
(Jersey above is for illustration purposes only, 2010 Jersey will be a different color)

 

The Dysautonomia Foundation is a registered 501(c)3 non-profit organization.


 Dysautonomia Foundation, Inc.
 315 West 39th Street, Suite 701
New York, NY 10018
Phone: 212-279-1066
Email: info@familialdysautonomia.org
 


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