Form to Donate Via Cash or Check

You may submit this form if you wish to donate using cash or check directly to a Rotary Club of Poipu Beach club member instead of using a credit/debit card online.

Your First Name

Your Last Name

Select donation level and drawing entries desired

Mahimahi Level, 1 entry at $30

Ahi Level, 4 entries at $100

Honu Level, 12 entries at $275

Kohola Level, 20 entries at $400

Name of Rotary Club of Poipu Beach sponsor

Select your desired method of contact for ticket numbers and prize notification

Via Email or Phone

Via Phone ONLY

Via Email ONLY

Please enter one or both

Depending on what communiction method(s) you selected above, you must enter either email address or phone number or both below.

Note: We must be able to contact you via one of these methods in order for you to win the prize.

Your email address

Your phone number

Have a question?

Feel free to ask a question or simply leave a comment.

Comments / Questions

NOTE: You will see a message on the screen when your form has been successfully submitted. If you do not see that message, it has not been sent.