Heinlein Society

Robert Heinlein, Virginia Heinlein, Snowy Heinlein

TO REPORT YOUR HONOR ROLL DONATIONS PLEASE
FILL OUT THE FOLLOWING FORM AND PRESS SEND

Please Read Before Filling Out and Sending the Information:

Fill in the blanks below to join the Heinlein Society's Honor Blood Drive
Only information in the PUBLIC HONOR ROLL section will be posted on our Honor Roll Page.
Please complete most fields - include either Phone, E-mail, or both.

Your information will remain private, except what you enter in the HONOR ROLL section, and authorized to be released and be used only for purposes directly related to the Society's Blood Drive.

Your Honor Commitment:

"On the date shown, at the place indicated, I certify on my Honor I donated one unit of blood or plasma and wish those facts recorded as evidence of my participation as an Honor Roll Donation for the memory of Robert Anson Heinlein by The Heinlein Society. I 'Pay It Forward'."

HONOR ROLL REGISTRATION INFORMATION FORM
The information below will be kept confidential and is used within the society only.

Title

First Name

Last Name

Street Address 1

Street Address 2 (e.g., PO Box, Apt. number)

City

State or Province

Zip/Postal Code

Country

Phone

E-mail

I certify on my Honor I gave one unit of blood or plasma in:

City

State or Province

Country

On this Date

Blood collection facility or hospital (e.g. "Red Cross bloodmobile" or "Kaiser-Permanente Hospital")

PUBLIC HONOR ROLL INFORMATION
The following information will appear on the website. You may enter your full name, first name only, or leave the entry as "anonymous".

my name:

city or organization
where I donated blood:

state or province:

country:

©2001-2010 The Heinlein Society
3553 Atlantic Avenue, #341
Long Beach, CA 90807-5606

The Heinlein Society was founded by Virginia Heinlein on behalf of her husband, science fiction author Robert Anson Heinlein, to "pay forward" the legacy of Robert A. Heinlein to future generations of "Heinlein's Children."

TO REPORT YOUR HONOR ROLL DONATIONS PLEASE FILL OUT THE FOLLOWING FORM AND PRESS SEND

TO REPORT YOUR HONOR ROLL DONATIONS PLEASE
FILL OUT THE FOLLOWING FORM AND PRESS SEND