Please print this form and mail it to us with your check, money order or credit card information. Please be sure to fill out all the information requested below so we can properly thank you for your gift and provide you with a receipt for tax purposes. If you wish to donate via the web, simply click on the donation button below. When you click the button you will be taken to Paypal, a service we use for donation processing. Paypal is 100% safe and secure and allows us to process donations, easily and securely. Paypal can be busy so it might be a few seconds before the donation page loads.

Thank you for helping us to pursue the cure for addiction!

                                                    

First Name:
Middle Initial:
Last Name:
Address:
Address 2:
City:
State:
Zip:
Country:
Phone:
Email:

Amount of donation:

$5,000 Chairman's Club                                                               
$2,500 Ambassador's Club
$1,000 Serenity Club
$500 Butterfly Club
$__________ Member

Please send an acknowledgement of this gift to:

Name
Address
City, State, Zip

(A letter acknowledging this gift will be sent to the person you specify stating that a gift has been made in honor of the person named. A dollar amount will NOT be included.)

_______________________________________________
(On each brick there is one line available for your inscription and 20 characters or spaces per line.) For additional bricks and their inscriptions, please contact us @ 206.244.8100