. _____$250 _____$500 _____$1000

_____$2500 _____$5000 _____ Other Amount

Donations can be made to honor someone on a special occasion, or in memory of a friend or relative.
An acknowledgement of your gift will be sent.

This donation is in honor of / memory of (please circle one) ____________________________

Please send an acknowledgement to:

Name: ________________________________________________________

Street: ________________________________________________________

City: ______________________________ State: _____ Zip Code: _______

Please print this form and mail it with your check payable to:

ALL DONATIONS ARE TAX DEDUCTABLE

THANK YOU FOR YOUR SUPPORT