Christmas Lighting Dedications Enrollment Form

Please print this form and mail the completed form and donation to:
Mount Alvernia, P.O. Box 858, Wappingers Falls, N.Y. 12590

A donation of $10.00 is requested for each person remembered to help defray the cost of the lights.

Your Name_________________________________________________________
 

Address___________________________________________________________
 

Address___________________________________________________________
 

Phone___________________________
 

Please light in honor or memory of:
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________
 

Name:_____________________________________________________________