Click here to order by fax (616.957.1169) or mail
(printable/faxable order form)

Click here to order online

ONLINE ORDER FORM: Fill in all fields below, submit, and then call the JDRF office with credit card information or send a check made payable to JDRF.

Name
Address
City
State
Postal / Zip Code
Phone Number
Email Address
Quantity	Select Quantity 1 2 3
Personalize It! Bracelets can be engraved with a special message; up to 3 lines with 10 characters per line (add $5.00 per bracelet for engraving)
Bracelet 1	Line 1:
	Line 2:
	Line 3:
Bracelet 2	Line 1:
	Line 2: .
	Line 3:
Bracelet 3	Line 1:
	Line 2: .
	Line 3: