Order Form

Please use the online form below to order The Hazel K. Goddess Fund's 14K Gold Lapel Pins and/or Stroke Emergency Wallet Cards. Bold fields are required.

Personal Information

Stroke Lapel Pin Order Form

I would like to order (enter quantity) of The Goddess Fund's gold plated lapel pin (gold over sterling silver) at a price of $45.00 each.*

*Please note there is an additional $5.00 shipping/handling charge per shipment. A Hazel K. Goddess Fund representative will contact you by phone regarding how and where to make payment for your stroke pin once your form is received.

Stroke Emergency Wallet Cards Order Form

Please send me of The Hazel K. Goddess Fund Stroke Emergency Wallet Cards (English version).
Please send me of The Hazel K. Goddess Fund Stroke Emergency Wallet Cards (Spanish version).