If the bottom is difficult to read, it says:

Please remit by 05/17/11 to: Nancy Mosburg PO Box 15067. Lenxa, KS. 66285 
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Family Name: ___________________________

Dinner: How Many: _______  X $40 = _______________
Picnic: How Many: _______  X $15 = _______________
Kids:   How Many: _______  X $6  = _______________   

Total Due: __________

Please remit by 05/17/11 to: Nancy Mosburg PO Box 15067. Lenxa, KS. 66285
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