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MY “GIFT OF CARE”
Please accept my "Gift of Care" to continue the mission of the Lafayette Community Health Care Clinic
My gift is $____________
___Monthly ___Quarterly ___Yearly ___One Time ___Other
Your name:________________________________________________________
Address:__________________________________________________________
City, State, Zip:_____________________________________________________
I certify that I will not receive any goods or services in return for making this donation.
Signature: ________________________________________________________
This donation is given in the name of:____________________________________
We will acknowledge your gift with an appropriate card to the recipients. Please include your gift list of names and addresses and indicate the occasion for the gift (birthday, holiday, memorial, etc.)
Mail this form to:
Lafayette Community Health Care Clinic
1317 Jefferson Street
Lafayette, LA 70501
Your Support is greatly appreciated.
Your donation is tax deductable.
Lafayette Community Heatlh Care Clinic is a 501(c)(3) organization.
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