Thank you for supporting our
programs and services. Please mail/fax your donation form to:
Stillwaters Cancer Support Services
FAX – (262) 513-5731
(Please PRINT all information
clearly)
Date ________________
___$30 ___$50 ___$100 ___$250 ___$500
___$1000 ___$5,000 $_______Other
Enclosed is a check payable to Stillwaters
Cancer Support Services or charge my credit card:
VISA____ MASTERCARD_______
Card #
____________________________________________
Exp. Date_______________
You have my authorization to charge
my credit card:
Name:_________________________________________
Address: ________________________________________________________________
Home phone: (______) __________________ Email ___________________________
City/State/ZIP:___________________________________________________________
(Receipt will be sent to the address
provided above.)
TYPE OF DONATION (please choose one):
General Donation, Sponsor a
Participant, Tribute gift in Honor of OR in Memory of :
_______________________________________________________________________
(name of
person)
Send acknowledgement card to:
Name:__________________________________________________________________
Address:
________________________________________________________________
City/State/ZIP:
___________________________________________________________
How would you like the card to be signed?
_____________________________________
(name or
names)
This donation will help Stillwaters
continue to carry out its mission, to provide support services to cancer
patients
and their families at no charge to
them. Your contribution is tax-deductible.
Stillwaters is a non-profit 501(c)
(3) agency (tax # 39-1818956) For more information
call