VFL Impact Award Ceremony

Contact Information

Organization Name:

Name:*

First

Last

E-mail:*

Phone:*

Area Code

Phone Number

IMPACT AWARD CEREMONY

Who will be attending the Impact Award Ceremony to accept the award?

Name 1:

First

Last

Name 2:

First

Last

Name 3:

First

Last

I will not attend the Impact Award Ceremony. (SKIP TO LUNCHEON RSVP)

Would you like a VIP guest to acompany you on stage to accept your award? (limit one)*

*** VIP guests are executives, managers, pastors or other high
level representatives from your organization. ***
A VIP guest is NOT required.

VIP Guest:

First

Last

VIP Guest Title:

VALENTINES FOR LIFE LUNCHEON - Main Event

Registration Fee: $10 per attendee

Please note: each table seats TEN.
For more than ten attendees, please complete the registration form multiple times as needed.

If you have any questions regarding payment ,
please email dgotcher@vitalant.org or call 480-675-5642.

Please only choose one of the payment options below.

# of Attendees:*

Payment Method:*

Pay Online Via Credit Card

Mail a Check

Sponsor/VIP

Outside Maricopa County (No Charge)

PAY VIA CREDIT CARD: Leave blank if using another method

Make checks payable to Vitalant
MAIL BY FEB. 1 TO:
Vitalant - Valentines for Life
6220 E. Oak Street
Scottsdale, AZ 85257

Attendee Information

Please list the names of all event attendees.

Attendee 1*

First

Last

Attendee 2

First

Last

Attendee 3

First

Last

Attendee 4

First

Last

Attendee 5

First

Last

Attendee 6

First

Last

Attendee 7

First

Last

Attendee 8

First

Last

Attendee 9

First

Last

Attendee 10

First

Last

DIETARY RESTRICTIONS

Please indicate the # of members in your group who have special dietary needs.
Servers at each table will be able to provide them with alternate options as long
as needs are expressed in advance.

Full Menu Below

Vegetarian

Vegan

Glutten Free

No Dairy

No Nuts

Other

Total: 0/10