C.U.R.E. Kits

First Name *

Last Name *

Email Address *

Phone Number *

Name of organization, if affiliated?

Name of recipient location *

Country of recipient location (clinic, hospital, orphanage, etc.) *

Special instructions

Number of C.U.R.E. Kits requested *

Address *

City *

State *

Zip *

Please confirm that the C.U.R.E. Kit will be in your possession at all times until delivery *

Please confirm that you will inform Project C.U.R.E. staff if the Kit is misplaced *

Your departure date *

Kit pick-Up *

Denver

Phoenix

Please ship to address on file

Payment preference *

pay by credit or debit online

pay by cash or check

Preferred date for C.U.R.E. Kit pick-up *

Contents of the C.U.R.E. Kit(s) will not be used in the United States *

True

False