Cancer Candidate Submission Form for Pink Ladies

If you know someone who has Cancer and could use a little help please fill out the following form.

"*" indicates required fields

Your Information

Please enter the following information about yourself so that we may contact you about the request.

Name*

Phone*

Address

Email*

Individual Information

Please enter the following information about the individual with Cancer. If you have email, that would be appreciated also. Please Note: *It is imperative that we have this information if we are to move forward.

Name*

Phone*

Address

Email

Tell us a little bit about the individual with Cancer please. What kind of Cancer? Do they have a family or spouse? Children? Are they able to work? What is their biggest need? Financial? A Pink Ladies Comfort Basket? If we are able to unburden them by stopping by and cleaning, doing yard work or possible some groceries, please let us know.*

Name

This field is for validation purposes and should be left unchanged.

Cancer Candidate Submission Form for Pink Ladies

Your Information

Individual Information

Thanksgiving Eve Karaoke Party with Nova Entertainment! Wednesday November 27th, 2024

Trivia Night with Full FX – First FRIDAYS of the Month PRIZES!!

Trivia Night with Full FX – First FRIDAYS of the Month PRIZES!!

TJz Colton Bar & Restaurant

TJz Colton Bar & Restaurant

HOURS OF OPERATION

Open Daily:

Monday – Sunday

11:00 am to 2:00 am
Kitchen Always Open!

(605) 446-3487

Off Sale & On Sale

Cancer Candidate Submission Form for Pink Ladies

Your Information

Individual Information

TJz Colton Bar & Restaurant

TJz Colton Bar & Restaurant

HOURS OF OPERATION

Open Daily:

Monday – Sunday

11:00 am to 2:00 am Kitchen Always Open!

(605) 446-3487

Off Sale & On Sale

11:00 am to 2:00 am
Kitchen Always Open!