27 Years of Hope in Action - On-Line Registration Form

Events

STEP 1) REGISTRATION FORM
Please make sure to enter your information accurately.

STEP 2) PAYMENT
You will be able to select U.S. Mail or On-line payment (Credit Card or Bank Transfer Via PayPal). You do not need a PayPal account to select this option.

You will be prompted to select an option once the registration form is complete.

Pay Pal

Prefix
First Name
Middle Initial/Name
Last Name
Suffix
Degrees
Title
Prog/Org/Instit.
Address
Address
City/State/Zip
Phone
Phone
Fax
E-mail
		You will receive an e-mail confirmation at this address.

Would you like to sign up to receive e-mail news from Casa Esperanza?
Yes No


If you are a sponsor or buying a listing in the program book, please indicate how you would like your name or organization to appear:
		Individual Name
		Program/Organization/Institution


Sponsorship
		NEW LIFE $27,000
		Celebrating Rick Quiroga's 27 years* of devoted service as Founder & Executive Director*
		Listed as Lead Sponsor in the Program Book and all event-related news releases
		Full-page greeting in Program Book
		Sponsor Logo displayed prominently on web site, on front cover of Program Book, & quarterly e-newsletter
		Thanked on PowerPoint shown at all “Action” events
		20 tickets to the event (two tables)*
		*2 tickets from each table are donated to Casa Esperanza’s graduates

		GRATITUDE $17,000
		Celebrating 17 years* of family based care for mothers & children at the Latinas y Niños Center*
		Listed as a Sponsor in the Program Book and all event-related news releases
		Full-page greeting in the Program Book
		Sponsor Logo displayed prominently on event web site and in quarterly e-newsletter
		Thanked on PowerPoint shown at all “Action” events
		10 tickets to the event (one table)*
		*2 tickets from each table are donated to Casa Esperanza’s clients

		COURAGE $7,000
		Celebrating 7 years* of evidence-based Relapse Prevention & Outpatient Services for clients*
		Listed as a Sponsor in the Program Book
		Full-page greeting in the Program Book
		Sponsor Logo displayed on event web site
		Thanked on PowerPoint shown at all “Action” events
		6 tickets to the event

		HOPE $2,700
		Supporting Casa Esperanza in its next 27 years* of innovative client-centered treatment*
		Sponsor Logo will be displayed on event website
		Listed as a Sponsor in the program book
		Half-page greeting in the Program Book
		Thanked on PowerPoint shown at all “Action” events
		2 tickets to the event

		Clear Selection

Individual Ticket Sponsor
All Individual Ticket Sponsors will be listed in the program book.

No. of tickets		I would like to sponsor tickets for community guests who can not afford the ticket price of $125.

Program Ads/Personal Messages for Rick
$750 Full page 5”(h) x 8”(w)
$375 Half page 5”(h) x 3.75”(w)
$150 Quarter page (Business Card) 2.5” (h) x 3.75”(w)
$50 Listing (Name/Organization as indicated)
Clear Selection

Copy received after May 10, 2011 will only appear in the Program Insert

Attend the Event
I would like to reserve tickets to attend 27 Years of Hope in Action: Honoring the Legacy of Rick Quiroga

No. of tickets		One Event Ticket includes dinner, program and dancing for $125
No. of tables		One Table includes 10 Event Tickets for $1,000

Payment
Payment deadline is May 25, 2011
Mail (Check or Money Order)
On-Line (Credit Card or Bank Transfer Via PayPal). You do not need a PayPal account to select this option.

Notes/Other Instructions


	You will be asked to review your selections on the next page before your submission is complete.

Last Updated 05-Feb-2012

Sponsorship

Individual Ticket Sponsor

Program Ads/Personal Messages for Rick

Attend the Event

Payment

Notes/Other Instructions