EmailMeForm
Nurse Educator Shirt Order Form
Please verify your information before submitting this form. Most fields on this form are required. Select NA or 0 for those areas not applicable.
You can pay via Venmo, CashApp, Cash or PayPal.
Venmo: @Dianne-Ricks
CashApp: $DeeWayRicks
Zelle: 504-430-3389
PayPal: @DianneWay or dwayricks@yahoo.com
Questions: 504-430-3389 or dwayricks@yahoo.com
Name
*
First
Last
Floor/Unit
*
Cell Phone/Work Phone #
*
###
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###
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Email
*
Thread Color (Select One)
*
Regular Gold
Antique Gold
DriFit Shirt Color
*
Black
Purple
White
Navy Blue
Red
NA (Ordering Cotton Shirt)
This is a multiple choice field. You are able to select multiple shirt colors.
Shirt Size
*
XS ($32.00)
Small ($32.00)
Medium ($32.00)
Large ($32.00)
XL ($32.00)
2XL ($34.00)
3XL ($34.00)
4XL ($37.00)
NA (Ordering Cotton Shirt)
The DriFit Shirts RUN LARGE so please make sure you select the correct size. XS only available for Pink Shirts. PLEASE VERIFY YOUR SHIRT SIZE BEFORE SUBMITTING ORDER FORM.
# DriFit Shirts Ordered (0 If ordering Cotton)
*
DriFit Shirt Total:(0 If ordering Cotton)
*
Calculate the number of drifit shirts ordered by the cost and place that value in this field
Name on DriFit Shirt or Other Info (NA If ordering Cotton)
*
Please double check this information for accuracy before submitting the form.
Cotton Shirt Color (Skip this entire section if you are not ordering a cotton shirt)
Black
Purple
White
Navy Blue
Red
This is a multiple choice field. You are able to select multiple shirt colors.
Cotton Shirt Size
Small ($20.00)
Medium ($20.00)
Large ($20.00)
XL ($20.00)
2XL ($22.00)
3XL ($22.00)
4XL ($25.00)
# Cotton Shirts Ordered
Cotton Shirt Total:
Calculate the number of cotton shirts ordered by the cost and place that value in this field
Name on Shirt or Other Info if ordering Cotton Shirt
Please double check this information for accuracy before submitting the form.
Total # of Shirts Ordered (DriFit+Cotton if applicable)
*
Add up the number of DriFit + Cotton shirts ordered and place that value in this field.
Total Amount Due: (Total For DriFit + Cotton Shirt if applicable)
*
Add up the DriFit Shirt Total + the Cotton Shirt total and place that amount in this field.
Please indicate your Payment Method
*
Venmo
CashApp
PayPal
Zelle
