TFCC Donation Form
Please print, complete, and mail to:
Teen and
Family Counseling Center, Inc.
Telephone (408) 370-9990 Fax (408) 370-9919 E-Mail donate@teenfamilycounseling.org
Section 1
Please enter as you
would like it to appear on our donor list or
specify if you would prefer the donation to be anonymous:
o I wish to remain
anonymous.
Name:
Address 1:
Address
2:
City:
State:
Zip:
Phone:
Section 2
o Enclosed is my tax deductible contribution,
as a:
Please check a box
below:
|
ž |
Type |
Dollar Amount |
|
o |
Sustainer |
$1,000 |
|
o |
Patron |
$500 |
|
o |
Support |
$200 |
|
o |
Support |
$100 |
|
o |
Sponsor – 2 Sessions |
$50 |
|
o |
Sponsor – 1 Session |
$25 |
|
o |
Other |
$________ |
|
o |
I would like to
receive a DVD copy of Ralph
Cantor’s workshop, Alcohol & Drugs:
Effect on the Adolescent Brain |
Please select a
contribution amount above. |
Make
check payable to:
Teen and
Or charge to: Visa/Mastercard # o
Expiration
date:
Signature:
o Enclosed is my firm’s completed Corporate
Matching Gift Form.
Company
name:
Thank you very much!