Order Form for Nursing Home Olympics Event Medals, Ribbons and Athletic Numbers

This form allows regional coordinators to submit an order for athletic numbers, medals and ribbons for their Nursing Home Olympics events.

Please note that each order will incur a $18 charge for USPS flat-rate shipping. After you complete this form and a staff member reviews it, an invoice will be sent to the email address provided. Please pay the invoice by check. Sending the invoice may take several days so please monitor your inbox. If you have any questions, contact Renee Bethel at rbethel@lnha.org or at 225.927.5642.

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* 1. Fill in your information

Full Name:

Facility Name: (no shorthand please)

LNHA Region:

Job Title:

Email address:

Date of Olympics Event:

Mailing Address:

City:

Zip:

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* 2. How many athletic numbers do you want to order? They are $.40 each.

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* 3. How many gold medals do you want to order? They are $3.40 each.

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* 4. How many silver medals do you want to order? They are $3.40 each.

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* 5. How many bronze medals do you want to order? They are $3.40 each.

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* 6. How many participant ribbons do you want to order? They are $.60 each.

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* 7. How many volunteer ribbons do you want to order? They are $.60 each.

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* 8. How many "You Make A Difference" ribbons do you want to order? They are $.60 each.

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* 9. Yes, I understand that this order will incur a $18 shipping fee to send this via USPS to the mailing address provided above.

Yes, I understand.

No, I do not want to place the order.

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* 1. Fill in your information

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* 2. How many athletic numbers do you want to order? They are $.40 each.

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* 3. How many gold medals do you want to order? They are $3.40 each.

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* 4. How many silver medals do you want to order? They are $3.40 each.

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* 5. How many bronze medals do you want to order? They are $3.40 each.

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* 6. How many participant ribbons do you want to order? They are $.60 each.

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* 7. How many volunteer ribbons do you want to order? They are $.60 each.

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* 8. How many "You Make A Difference" ribbons do you want to order? They are $.60 each.

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* 9. Yes, I understand that this order will incur a $18 shipping fee to send this via USPS to the mailing address provided above.

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* 10. Based on the order information above, my total with the shipping fee of $18 is: