Name: _____________________________________________ 

Address: _________________________________________ City: ________________ Zip code: ___________

Phone: _____________________   E-mail: __________________________

Please send what you can afford!
Indicate the amount you are donating:

_____ $  10         _____ $  20        _____ $  50      _____$  100            _________ $ All  other amounts

To volunteer your time and talents, call:  223-7501