Date: Saturday, November 11, 2017
Time: 6:00 PM

Location: The Center Club
100 Light Street 16th Floor
Baltimore, MD 21202


* Choose all that apply:    I would like to attend the An Evening with the Stars Event
 I would like to Honor a Nursing Star
 I would like to make a donation to the Baltimore Talent Scholarship

Event Registration



$100 General Admission (Tax deductible $55)  $100.00 Qty: Total:
Total Number of Attendees  


Honor A Star



Honor A Nursing Star - GOLD $500  $500.00 Qty: Total:
Honor A Nursing Star - SILVER $250  $250.00 Qty: Total:
Honor A Nursing Star - BLUE $125   $125 Qty: Total:
Honoree's Name to Appear 
Honoree's Address 
Honoree's Address 2 
Honoree's City 
Honoree's State  
Honoree's Zip 
Honoree's Country  




Donation



I would like to make a gift in the amount of (Fully tax deductible) 


Total



Total to be charged to credit card 


Personal Information



* First Name 
* Last Name 
*Affiliation  
* E-mail 
* Phone 
* Address 
Address 2 
* City 
* State  
* Zip 
* Country  
Additional Guest #1 Name 
Guest #1 Affiliation  
Additional Guest #2 Name 
Guest #2 Affiliation  
Additional Guest #3 Name 
Guest #3 Affiliation  


Credit Card Information



* Name as it appears on credit card 
* Card Type  
* Card Number 
* Expiration Month/Year     
* CVV 
CVV is a 3-digit number on the back of a VISA or MasterCard; it is a 4-digit number on the front of an AMEX.

For questions or dietary restrictions please contact Shelia Love at slove1@jhu.edu.