Teen Video Order Form - Price Includes Study Guide

Name __________________________________________________________

Address ________________________________________________________

_______________________________________________________________

Organization ____________________________________________________

Home phone ______________________ work phone ___________________

cell phone ______________________ E-mail _________________________

Quantity _______ @$35 each = __________________.

Please print form and mail with check to:
The Adelphi NY Statewide Breast Cancer
Hotline & Support Program
Adelphi University School of Social Work
1 South Ave, PO Box 701
Garden City, NY 11530

Would like to pick up your order at the program offices? Please call 516.877.4320 to arrange a time.

This video and study guide were created by:
The Adelphi NY Statewide Breast Cancer Hotline
& Support Program

Video and study guide were developed with and funded through a grant from The Greater New York City Affiliate of the Susan G. Komen Breast Cancer Foundation. Additional funding provided through a legislative grant from New York State Senator Kemp Hannon. Photos: Eileen Miller

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Adelphi NY Statewide Breast Cancer
Hotline & Support Program

All Services Are Free And Confidential.