Donation Form

Your Contact Information

First Name
Last Name
E-mail
Phone
Address
City
State
ZIP

Donation Details

Annual Fund amounts

Jackson Society: $500 +
Leadership Associates: $1,500 +
Partners’ Council: $2,500
Legacy Club: $5,000 +
President’s Circle: $10,000 +

Amount	Please enter amounts without the '$' sign
Donation Designation	If you selected 'Other' please specify below
(Other Designation)

Tribute Donation

If you are giving a tribute donation, please use the form below to provide the contact information of the person to be notified of your gift.

My gift is in Honor/Tribute of
My gift is a Memorial to
Please Notify (Name)
Address
City
State
ZIP

Matching Funds

Do you have matching funds available? If you have matching funds available or you are not sure, please provide the name of who will be matching below.

Name

Listing in Print and Media

Provide your name as you would like it to appear in our print and media publications.

Name	If you wish to be listed as anonymous, please type the word 'anonymous' in the textbox.

In accordance with IRS regulations, please note that no goods or services were given in exchange for this gift. Please retain this letter for your records. A copy of the Council's official registration and financial information may be obtained from the Pennsylvania Department of State by calling toll free within PA 1-800-742-0999. Registration does not imply endorsement.