CWD Products Order Form

Print this page, fill it out, and then mail or fax to the address at the bottom.

Bracelet Price Including Shipping:
  • $2 per to US addresses
  • $2 per plus shipping to all other addresses
    		•   T-Shirt Price Including Shipping:
  • $15 per shirt to US addresses, shipping included
  • $20 per shirt to all other addresses, shipping included

    • Name  
    Address  
    City   State   ZIP/Postal Code  
    County if in Ohio   Country  
    Telephone   Email  

    Bracelets Quantity Price Per Total Price
    Red Bracelet Red "Insulin is Not a Cure" Bracelet: Adult (210 mm)     $
    Red "Insulin is Not a Cure" Bracelet: Child (190 mm)     $
    Blue Bracelet Blue "I Believe" Bracelet: Adult (210 mm)     $
    Blue "I Believe" Bracelet: Child (190 mm)     $
    Insulin is not a Cure T-shirts Qty Black with
    White Lettering    		 Qty White with
    Black Lettering    		 Price Per Total Price
    Blue Bracelet "Insulin is Not a Cure" T-Shirt, Youth Small       $
    "Insulin is Not a Cure" T-Shirt, Youth Medium       $
    "Insulin is Not a Cure" T-Shirt, Youth large       $
    "Insulin is Not a Cure" T-Shirt, Adult Small       $
    "Insulin is Not a Cure" T-Shirt, Adult Medium       $
    "Insulin is Not a Cure" T-Shirt, Adult Large       $
    "Insulin is Not a Cure" T-Shirt, Adult X Large       $
    "Insulin is Not a Cure" T-Shirt, Adult XX Large       $
    Product Subtotal $
    Sales Tax [Only Michigan & Ohio] (Michigan 6%, Ohio residents add your county sales tax) $
    Grand Total $

    Payment Information
    [     ] VISA or MasterCard Card Number:  
    Expiration Date:   Security Code:  
    [     ] I am enclosing a check payable to "Children with Diabetes" (non-US orders require credit card)

    To Mail Your Order:     Children with Diabetes, Inc.
    8216 Princeton-Glendale Road, PMB 200
    West Chester, OH 45069-1675     		    To Fax Your Order:     (513) 755-9963