Dignity Kids, Inc. : Individual Pink Belt Purchase

Wishing for Mommy was founded to empower and enable the children of mothers who are battling or recovering from Breast Cancer. The Wishing for Mommy campaign is sponsored by Dignity Kids, Inc., which is a 501(c)(3) nonprofit organization.

The Pink Belt Revolution is a fundraiser in support of Wishing for Mommy pioneered by martial arts school all around the country.

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Please note that this form contains limited capacity items which are sold out. They are displayed grayed out and/or are not selectable.

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Registrant Fee:		$0.00
Group Fee:		$0.00
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Billing information

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Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*DIGNITYKIDSINC 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

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Registration inquiries:
Dignity Kids, Inc.
Tel: (480) 831-1111
www.dignitykids.org

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Registrant

Purchase an Individual Wishing for Mommy Product

First Name

Last Name

Phone

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I am a Martial Arts Student/Parent
I am NOT a Martial Arts Student/Parent

Name of your Martial Arts school

City & State your school is in

Name of your Instructor

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Ship or Pick Up?

If you are purchasing a pink belt online today locally (AZ), please print your confirmation and bring it to your instructor to receive your belt.

What location are you picking up from?

Shipping Address

Quantity of Size 1 Belts ($20)

Quantity of Size 3 Belts ($20)

Quantity of Size 5 Belts ($20)

Quantity of Size 7 Belts ($20)

Quantity of Size 9 Belts ($20)

Quantity of 2019 Patches ($20)

Quantity of 2018 Patches ($10)

Quantity of 2017 Patches ($10)

Quantity of 2016 Patches ($10)

Quantity of Small Wristbands ($10)

Quantity of Large Wristbands ($10)

Thank You for Your Contribution.

You will be able to see these wishes come true as they unfold in December. Updates and Stories will be posted on www.WishingforMommy.org

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