ORDER FORM

Your dollars make a difference in the lives of kids with juvenile scleroderma, and their families!

THANKS FOR SUPPORTING THE JSDN!!!

ITEM QUANTITY COST TOTAL
Light Blue: Medium Wristband   @ $2.00 each $
Light Blue: Large Wristband   @ $2.00 each $
Light Blue: Child Wristband   @ $2.00 each $
Glow-in-the-dark: Medium Wristband   @ $2.00 each $
*Please note: Medium should fit most kids and adults, and child size should fit most 4 to 6 year olds. TOTAL ENCLOSED
(Payable in U.S. Funds ONLY)
$

 

 

Name:___________________________________Email:____________________________


Address:_______________________________________Phone:______________________

City:_________________________________________State___________Zip___________

Mail check or money order along with your order form to:
JSDN - Store
1204 W. 13th Street, San Pedro, CA 90731

Any questions about your order call 310-519-9511 or
Email