T-Shirt Order Form

Name
Address
City
State
Zip
phone (Optional)
Email

Pink Youth Short Sleeve	Pink Adult Short Sleeve	White Youth Short Sleeve	White Adult Short Sleeve	Black Youth Long Sleeve	Black Adult Long Sleeve
XS	S	XS	S	XS	S
S	M	S	M	S	M
M	L	M	L	M	L
L	XL	L	XL	L	XL
	XXL		XXL		XXL
	XXXL		XXXL		XXXL

Additional Information/Comments:

Contact me about speaking to my group or starting a group

Security Code: - Please type in the word "prayer" (no quotes).

A suggested donation of $5 - $10 per shirt payable to Sam's Rock would be appreciated, as our non-profit status is pending. All other donations are also welcome to further our outreach and will become tax deductible once our application is approved. Mail to: Sam's Rock, 2802 Sexton Dr., Louisville, KY 40223.