Jesus Is Lord!

From the Heart Church Ministries®

Bishop John A. Cherry, II - Pastor

2015Pink BanquetInformation Form

Praise the Lord! If you desire to identify and highlight yourself or your family member as a Breast Cancer survivor at the upcomingPink Banquet, please provide the requested information below. This form may also be used to identify family members that have passed away during the In Memory portion of thePink Banquet program. The information collected on this form will be shared at the2015PinkBanquet to take place on October 17, 2015. This information will not be shared in any other manner.

** Completed form must be sent NO LATER THAN Friday, October 2nd to . **

BREAST CANCER SURVIVORS

Survivor’s Name: / FTH Member: Yes No
Please check one.
Survivor’s Email:
Will only be used to provide updates regarding the Pink Banquet. / Year of Diagnosis:
Are you willing to be identified at the upcomingPink Banquetas a Breast Cancer Survivor? Yes No
Are you willing to participate in the program as a Breast Cancer Survivor? Yes No
Are you willing to have your name printed as a Breast Cancer Survivor? Yes No
If yes, it will printed as the name you provide on this Form. Please ensure spelling is accurate.

** Completed form must be sent NO LATER THAN Friday, October 2nd to . **

DEPARTED LOVED ONES

Family Member’s Name: / Year of Death: / Age:
Family Member’s Name: / Year of Death: / Age:
Family Member’s Name: / Year of Death: / Age:
Family Member’s Name: / Year of Death: / Age:
Person providing Information: / FTH Member: Yes No
Please check one.
Email:
Will only be used to provide updates regarding the Pink Banquet. / Phone:
For clarifying questions, if any.
By submitting images and/or videos of your deceased loved one, you acknowledge and give permission to From the Heart Church Ministries®, its staff, officers, directors, or volunteers to post, display and/or print them during the 2015 Pink Banquet to take place on Saturday, October 17, 2015. This includes printing of the Banquet program to be distributed to all Banquet attendees. The decision to post will be that of From the Heart Church Ministries®, its staff, officers, directors, or volunteers.
Electronic Signature: / Date:
High Resolution jpg file(s) attached? Yes No
No more than three images will be displayed. / Video media attached? Yes No
No more than 2 minutes will be displayed.

From the Heart Church Ministries®, ANNEX at 5055 Allentown Road, Suitland, MD 20746, , (301) 899-9411