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					FAMILY & CHILDREN’S SERVICES FOUNDATION

GIFT REPLY FORM
YES! I would like to make a difference in the life of a child or youth from this community.
(Mr./ Mrs. / Ms.) Name: ___________________________________________________________________________ Address: __________________________________________________________________________________________ City: ______________________________ Prov: _______ PC: ______________ Phone: _______________________ Email address: _____________________________________________________________________________________ We recognize our supporters in the Foundation Report. Please indicate how you would like your name to appear (if different from above). If you wish to remain anonymous, please indicate that on the space provided. ________________________________________________________________________________________

I wish to make a gift of I would like to designate my gift to
A list of all funds is available on online at www.facswaterloo.org/foundation

I WISH TO MAKE MY GIFT BY CASH or CHEQUE. CREDIT CARD. (please circle) Visa MasterCard American Express

#: ________________________________________________________________ Expiry date: _______________________ _____ My company has a matching gift policy.

Matching Gift Company: ___________________________________

I WOULD LIKE TO MAKE MY GIFT ‘IN HONOUR’ OF SOMEONE
My gift is: _____ In Memory ____ In Celebration _____ Please send a card in acknowledgment. If yes, please enter contact information below: Name of recipient/next of kin: ______________________________________________________________________ Address: _________________________________________________________________________________________ City/Prov/PC: ___________________________________ Phone: __________________________________________ What message would you like to have appear in the card? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

For your convenience, this form may be faxed to (519) 570-0160 or mailed 200 Ardelt Avenue, Kitchener, Ontario N2L 2C9


				
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