Childhood Cancer Campaign (CCC) Revenue Submission Form
A) All CCC Revenues raised by U.S. and Caribbean Members and submitted to the Optimist
International Foundation in St. Louis, MO should be sent via check made payable to OIF – CCC.
The mailing address is: Optimist International Foundation
4494 Lindell Blvd., St. Louis MO, 63108
B) All CCC Revenues raised by Canadian Members and submitted to the Optimist International
Foundation of Canada should be sent via check made payable to Optimist International
Foundation of Canada, with CCC in the memo portion.
The mailing address is: Optimist International Foundation of Canada
5205, boul. Metropolitain est, Suite 200 Montreal, Qc H1R 1Z7
C) Please complete the applicable sections below and enclose this form with the revenue
remittance.
I. Revenue Source
(please check the applicable blank and provide information requested)
____ CCC coin bank revenue Amount _________
____ Club CCC fundraising/donation revenue Amount _________ Club #____________
____ District CCC fundraising/donation revenue Amount _________ District #_________
____ Individual CCC donation Amount _________ Member #____________
(if applicable)
____ CCC Awareness Month fundraiser – Club/District
Name and #_________________________________________ Amount __________________
____Optimist Research Fellowship in Pediatric Oncology at Johns Hopkins Fund donation
____ Memorial ____ Tribute Name __________________________________________________
Send acknowledgement to: ______________________________________________________
at (address)_______________________________________________________________
________________________________________________________________
II. Revenue Designation*
(please check one option and provide any information requested)
______ OIF-CCC General Fund ______ Optimist Research Fellowship at Johns Hopkins
*All submitted CCC Awareness Month Revenues will automatically be designated for the research fund.
CCC coin bank revenues submitted cannot be designated/restricted by Clubs, and will be deposited in the
CCC General Fund.
Name (Club/Zone/District/Member) ____________________________________________________
Address ____________________________________________________________________________
Phone (H) __________-_______________________ (W)________-______________________________
E-mail ____________________________________________________________________________
Date ______________________________________________________________________________
Total amount submitted with this report ________________________________________________
