A Night For Champions
Table Reservation Form
Please fill out the form below to attand A Night for Champions:
(benefits listed on Sponsorship Levels page)
Gold Sponsorship $25,000+
Silver Sponsorship $10,000
Bronze Sponsorship $5,000+
Patron Sponsorship $3,500
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Table(s) for 10:$2,000/table
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Single Ticket(s):$200/guest
I am interested in placing an ad in the program. Please contact me.
Contact Name:
Mailing Address:
City, State, Zip:
Phone, Email:
Register and pay via
or by
You will be invoiced. Make check payable to:
N. Donald Diebel, Jr., M.D. Good Samaritan Fund
and mail to:
A Night for Champions - P.O. Box 2150, Winter Park, FL 32790
A discounted block of rooms will be held for guests wishing to stay overnight at The Ritz-Carlton Orlando Grande Lakes. Please request the preferred rates for the A Night For Champions group at 888-707-9325.
