Miriam’s Fundraising Submission Form

Miriam’s Fundraising Submission Form!

Thank you for considering being apart of our fundraiser! 50% of the proceeds go towards Miriam’s cancer treatments. We can ship or you can pick up at Elite Nutrition in Fargo!
Products
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E1 - Cherry Limeade - 6 Pack
Flavor: Cherry, Lime & Lemon - Power Tea

$40.00 Quantity



E2 - Bomb Pop - 6 Pack
Flavor: Blue & Red Raspberry & Pomegrante - Power Tea

$40.00 Quantity



E3 - Grape Escape - 6 Pack
Flavor: Grape, Orange & Lemon - Power Tea

$40.00 Quantity



E4 - Pineapple Push - 6 Pack
Pineapple, Tropical & Raspberry - Power Tea

$40.00 Quantity



L5 - Lemon Pom Pom - 6 Pack
Flavor: Strawberry Lemonade + Pomegrante - 75 mg Caffeine & Collagen

$40.00 Quantity



L6 - Watermelon Crush - 6 pack
Flavor: Orange, Watermelon, Raspberry. 85 mg Caffeine & Hydration

$40.00 Quantity



L7 - Acai Berry Twist - 6 pack
Strawberry Lemonade, Acai, Orange, Hydration & Collagen

$40.00 Quantity



12 Pack Power Tea Kit
12 different flavors to try!

$80.00 Quantity



Shipping

$8.00 Quantity



Total

$0.00
Name

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address- If needing shipping option

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

Miriam’s Fundraising Submission Form!