Name
_________________________________________________________
Address
_________________________________________________________
_________________________________________________________
Phone #
_________________________________________________________
E-Mail
_________________________________________________________
Amount of Donation: $_____________
Do you wish your donation to go toward a specific cause?
check all that apply:
___ Polio Plus
___ Community Gifts
___ International Needs
___ College Scholarships
___ Welcome Home Awards
___ Back to School for Health
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