SHIP TO:

NAME_______________________________________________________________________

ADDRESS___________________________________________________________________

CITY______________________________________STATE___________ZIP_______________

PHONE____________________________________E-mail_____________________________

BOOK - $10.00 donation
     QUANTITY  __________   (shipping in US only - 1-3 books, $5.00 ) = $______________

DVD - $50.00 donation
      QUANTITY  __________   (shipping in US only - 1-3 DVDs, $5.00 )= $______________

                              (Mailing rates will vary with additional quantities shipped)

CAREGIVER’S GUIDE to Caring for Drug Exposed Infants -  $3.00 donation
      QUANTITY  __________  X $3.00 each (shipping included – US only)= $____________

                                                                                                        
                                                                                   TOTAL ORDER     $ ______________
o    CHECK ENCLOSED

o CHARGE MY:      o VISA     o MasterCard  

CREDIT CARD NUMBER_______________________________EXPIRATION_______________

Name as it appears on credit card__________________________________________________

Billing address_________________________________________________________________

City______________________________________State________________Zip_____________

Signature_______________________________________________Phone_________________

 PRINT THIS FORM and MAIL TO:
 Pediatric Interim Care Center, The Newborn Nursery
 328 4th Avenue South
 Kent, WA  98032