Fields marked * require an entry.

Winery Donation Form

Item Information

Item Name:*

*Please enter a value

Estimated Value $:*

*Please enter a value
Please enter a valid decimal number as nnn.nn

Item Description:*

*Please enter a value

Item Restrictions (blackout dates, etc.):

I am a(n):*

Individual Donor

Business Donor

*Please enter a value

I would like to remain anonymous:*

Yes

*Please enter a value

Please indicate how you would like the donor listing to appear:*

*Please enter a value

By checking this box, I am confirming that, as the donor of this item, the estimated value state above is accurate to the best of my knowledge:*

Yes

*Please check box to continue.

I have a photo and/or logo I would like to include to help market my item donation. Please contact me for the file(s):*

Yes

*Please enter a value

Certificate Donations

If your item donation is (or contains) a certificate, please select one of the following options:

I will mail a certificate to the office.

I will email an electronic certificate to Madisen Rogers at mrogers@akwa.wish.org.

I would like Make-A-Wish to create a certificate for me.

If you would like Make-A-Wish to create a certificate for you, please indicate the contact name and information you would like us to share with the winning bidder:

Contact Information

Company:*

Please enter a value for Company:

First Name:*

Please enter a value for First Name:

Middle Name:

Please enter a value for Middle Name:

Last Name:*

Please enter a value for Last Name:

Address:*

Please enter a value for Address:

Address2:

Please enter a value for Address2:

City:*

Please enter a value for City:

State:*

Province State is required for the United States

Postal Code:*

Please enter a value for Postal Code: Please enter a valid postal code.

Country / Location:*

Country is Required

At least one phone number is required.* Please enter at least one phone number

Mobile Phone:

Please enter a value for Mobile Phone: Please enter a valid phone number. Use x to denote extension

Work Phone:

Please enter a value for Work Phone: Please enter a valid phone number. Use x to denote extension

Email:*

Please enter a value for Email: Please enter a single valid Email.

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