Bacchus form

Bacchus Ball February 1, 2025
If you have any questions call the Diabetes Foundation of Mississippi at 601-957-7878.

Registration closes Noon Thursday January 30, 2025.

Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Sponsor Registration Options - Royal Court will Be listed on the programs
Guest List - Please list attendees if known. Sponsorships include 2, 4, 6, 10, or 20 Seated Guests.
Total
$0.00
Billing Address*
Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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Name
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