Purchaser's name:
Student's name:
Phone number:
Email address:
Date:

Order pickup:
I will pick up the order from the band room
Please give the order to my child

Band (please check one)
Grade 5
Junior 6
Junior 7
Intermediate Band
Senior Band
Not in music program

Number & type of gift cards

	Co-op	Safeway	Sobey's	Superstore
$25
$50
$100
$200
$250
Total:

Special instructions

this form directly from your browser, or use this PDF version.

You can use this form two ways:

1. In your browser:
   1. Type into the form in your browser. Take care to calculate the total correctly.
   2. Then print the form. It should print with all your information included.
2. OR manually, just print the empty form, and fill in the empty boxes with a pen or pencil.

Submit the form, along with payment, to Jane Leslie, Band Aide. Make cheques payable to Westmount Music Association.

Note that with gift cards, you will not get change. ANY REMAINING BALANCE WILL STAY ON THE CARD. YOU MAY USE THE CARD UNTIL THE BALANCE IS $0.00.