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Package Name Amount Quantity Subtotal

$25,000 Fund A Cure $0.00

$10,000 Fund A Cure $0.00

$5,000 Fund A Cure $0.00

$2,500 Fund A Cure $0.00

$1,000 Fund A Cure $0.00

$500 Fund A Cure $0.00

$250 Fund A Cure $0.00

$100 Fund A Cure $0.00

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I authorize Breakthrough T1D - Orlando - 4134 to use the credit card entered on the submission page at event 13th Annual Imagine Gala. Once the transaction has completed successfully, a confirmation receipt will be sent to the email address entered.