The Children's Healing Institute

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PARTNERS

Hot Havana Nights
Saturday March 13th @ Seminole Hard Rock Hotel and Casino
Complete and submit this form to purchase tickets for this event.
If you prefer, you may purchase tickets over the phone by calling 561.585.1650.
Tickets will also be available at the door the night of the event.

Name:    Title: (optional)

Agency, Organization or Business: (optional)

Address:

City:    ST:    Zip:

Email:

Phone:    Fax: (optional)

Quantity of tickets you wish to purchase: @$150 per ticket

Please enter the names of the additional guests you are buying tickets
for in the fields below:

Guest Name:
Guest Name:

Guest Name:
Guest Name:

Payment Information:

Card Type:

Card Number:

Expiration Date: / (MM/YYYY)

Name on Card:

Credit Card Billing Address is the same as the Registration address. If not, please enter the billing address below.

Billing Address:

City:

State: Zip Code:

Once you submit this form you will be sent an email confirmation with the information you entered and the amount charged.