CELLIE COPING KIT ORDER FORM
CELLIE
ORDER FORM
The following methods can be used to place an order.
Fax: Cellie-VEC at 215-590-2025,
Attention Denise Freeman
Call: 215-590-3159
Email: [email protected]
Visit Our Website: www.celliecopingkit.org
Mail Form to Denise Freeman:
Cellie - VEC
The Children's Hospital of Philadelphia
3615 Civic Center Boulevard, ARC Room 1202
Philadelphia, PA 19104-4318
SHIPPING ADDRESS
Name: ________________________________________________________________________________________________
Practice/Company: ______________________________________________________________________________________
Street Address: _________________________________________________________________________________________
City: __________________________________________
Phone Number: _________________________________
State: ______________________
ZIP: _________________
Fax Number: ________________________________________
BILLING ADDRESS IF DIFFERENT FROM SHIPPING
Name: ________________________________________________________________________________________________
Practice/Company: ______________________________________________________________________________________
Street Address: _________________________________________________________________________________________
City: __________________________________________
Phone Number: _________________________________
State: ______________________
ZIP: _________________
Fax Number: ________________________________________
PAYMENT METHOD
Check or Money Order Made Payable to The Children’s Hospital of Philadelphia Research Institute
Purchase Order #______________________________________________________________________________________
Master Card
Visa
American Express
Discover
Card number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _ Exp. Date: _ _ / _ _ (mm/yy)
Name as it appears on credit card: _______________________________________________________________________
Signature: ___________________________________________________________________________________________
The Children’s Hospital of Philadelphia • 3615 Civic Center Boulevard, ARC Room 1202, Philadelphia, PA 19104-4318 • Phone: 215-590-3159 • Fax: 215-590-2025
PLEASE CHECK ONE THE FOLLOWING:
CELLIE
ORDER FORM
Which best describes you? I am a__________.
____ Parent/Caregiver
____ Nurse
____ Physician
____ Child Life Specialist
____ Mental Health Provider
____ Foundation
____ Hospital
____ Other (Please specify):
PRODUCT DESCRIPTION
PRICES
*SHIPPING RATES
Includes Toy, Book, Card Deck in Carrying Box
and Drawstring Bag
$45.00
$8.00
Cellie Coping Kit for Cancer
$26.00
$8.00
Cellie Coping Kit for Cancer
$15.00
$8.00
Cellie Coping Kit for Cancer
$15.00
$8.00
Cellie Coping Kit for Cancer (Spanish)
$45.00
$8.00
Cellie Coping Kit for Cancer (Spanish)
$26.00
$8.00
Cellie Coping Kit for Cancer (Spanish)
$15.00
$8.00
Cellie Coping Kit for Cancer (Spanish)
$15.00
$8.00
Includes Toy, Book, Card Deck in Carrying Box
and Drawstring Bag
$45.00
$8.00
Cellie Coping Kit for Sickle Cell Disease
$26.00
$8.00
Cellie Coping Kit for Sickle Cell Disease
$15.00
$8.00
Cellie Coping Kit for Sickle Cell Disease
$15.00
$8.00
Cellie Coping Kit for Cancer
Toy Only
Book Only
Card Deck in carrying box Only
Includes Toy, Book, Card Deck
Toy Only
Book Only
Card Deck in carrying box Only
Cellie Coping Kit for Sickle Cell Disease
Toy Only
Book Only
Card Deck in carrying box Only
QUANTITY
COST
*Please call 215-590-3159 for shipping charges on orders of two or more.
Please allow three to four weeks for delivery; larger orders may be subject to a longer delivery.
To make a donation to help children with cancer, please visit our website at : www.celliecopingkit.org
The Children’s Hospital of Philadelphia • 3615 Civic Center Boulevard, ARC Room 1202, Philadelphia, PA 19104-4318 • Phone: 215-590-3159 • Fax: 215-590-2025