West Kauai Medical Center Charitable Foundation

BENEFITTING

HOSPITAL

PROGRAMS

&

MEDICAL

EQUIPMENT

Any Donations from the community or gifts will be accepted. Sponsor can be in the Form of:
1) Platinum--$1,000 and above,

$100

includes green fees, lunch, cart, & awards {$28 donation to foundation}

Sunday October 28th

Poipu Bay Golf Course 2 Person Scramble Early Bird Registration - October 24th

2) Gold--$500 and above, 3) Silver--$300 and above, 4) Bronze--$100 and above.

Golfers
REGISTRATION FORM:
Name:________________________________ Handicap: _____________________________ Address: ______________________________ Phone: _______________________________ Email: _______________________________ Mulligan: _____________________________ Total Amount Enclosed $_____________________ Closest to pin for all par 3s.........................$10 Mulligans................$5 each (3 max per person) Great prizes -- Place Prizes -- should be longest Drive Closest to the Pumpkin on all par 3s
for men & Door women Prizes

Each Hole sponsor will receive a sign at a designated Hole on the course. Door prizes are always welcome as well.

Name of Company:__________________________ Address:___________________________________ Contact Person:_____________________________ Phone:_______________ Fax:_________________ Email Address:______________________________

Shot gun start at 8:00 am ~ Halloween Theme ~

1) One free mulligan with a carved/decorated pumpkin. 2) Prizes for the best carved/decorated pumpkin. Costumes welcome -- Best costume contest.

I/We would like to be a Platinum, Gold, or Silver Sponsor for $ I/We would like to be a Gold, Silver, Bronze Hole Sponsor for $ I/We would like to donate an In-Kind Gift/Door Prize Description of Donation: Value of Donation $

Reception To Follow at The

I/We will deliver donation to the West Kauai Medical Center/KVMH-O.T. Department on:
date

GRAND HYATT BALLROOM

I/We would like to the donation to be picked up by:

date

Please make check or donation out to: KVMH Charitable Foundation PO. Box 1193 Waimea, HI 96796