DONOR INFORMATION

Last name:

First name:

MI:

Address:

City: State:

Zipcode:

Home Phone Cell Phone

Email: Envelope Number:

PLEDGE INFORMATION

I (we) hereby contribute cash and/or assets to the DARE TO IMAGINE FUND.

I (we) pledge a total of $

I (we) wish to contribute Weekly Monthly Yearly.

CONTRIBUTION FORM

I (we) plan to make my (our) contribution in the form of:

Cash Check Card

Automatic Deduction Yes    or No

DONOR RECOGNITION

(Donors will be recognized in campaign materials unless an anonymous gift is requested)

Please use the following name's in all acknowledgements:   

or     I (we) wish to remain anonymous