Donation Form

Donate:

I would like to make a tax deductible contribution of:

Platinum Partner....	$10,000	Special Donor......	$100
Gold Partner.........	$5,000	Friend..................	$50
Silver Partner........	$2,500	Other...................	$
Major Gift.............	$250

Donor's Information

First Name:	Last Name:
Address:	City:	State/Zip:
Phone:	Fax:

Any Special Designation (such as in someone's memory -- please include their name):

Purpose of Gift: Is your gift for general operations? Or toward one of the following programs?

If so, please indicate which of the following:

Kaboom Project at Guadalupe Park
Free Child Services
Free Child SafetyHelmets and Carseats
FamilyWelfare/Emergency Assistance
Holiday Cheer (food, toys, gift cards, cash,clothing)
I would like to volunteer at the Center (Staff member will contact you at thenumber above)

Billing Information

Title:		Street 1:
First Name:		Street 2:
Middle Name:		City:
Last Name:		State:
Suffix:		Zip Code:
Email Address:		Country:
	I may be contacted by email	Company Name:

Tribute Gift Information

Yes, this is an honor or memorial gift.

Recipient First Name:

Payment Information

Credit Card Type :
Credit Card # :
CVV Number :
ExpirationDate:	(ex. 06/10)