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Genoa Medical Center

Nebraska Shirt Fundraiser Form

Genoa Medical Facilities Nebraska shirts as a fundraiser for our air conditioner.
Soft Canvas Brand Unisex T-Shirts
The air conditioner at Long Term Care is aged and in need of replacement to provide comfort for the residents and staff that live and work at Genoa Medical Facilities. All proceeds from the t-shirts will go into the air conditioning fund. Order Deadline: August 30, 2019. Shirts will be delivered to the school or hospital just in time for the first Husker football game.
* Name
Full Name.
* Phone Number
  Email Address
* Shirt Type
Please select shirt type.
Football     Good Life    
* Soft Canvas Brand Unisex T-Shirts - $14
Please select your size.
Youth-Small
Youth-Medium
Youth-Large
Adult-Small
Adult-Medium
Adult-Large
Adult-XLarge
  Soft Canvas Brand Unisex T-Shirts- $16
Please select your size.
Adult-2XLarge
Adult-3XLarge
Adult-4XLarge
Adult-5XLarge
* Total Number of Shirts
Please list quantity of each size you would like here. (Example: 2 Small good life, 1 Large Football, 1 Large Good life)
* Amount $
* Name on the Card
* Card Type Visa     Mastercard     American Express    
* Credit Card Number
* Expiration Date
00/0000
* Security Code
Number located on the back on the card.
* Zip Code