Enclosed is my contribution in the amount of:

r $50           r $100       r $250       r $500 

r $_________

Name_______________________________________

1

I would like my gift to support:

Address_____________________________________

q            Crisis Treatment Services  

City, State, Zip________________________________

q            Family Life Center

Daytime Phone________________________________

q            Paladin House

Evening Phone________________________________

q            Greatest need

E-mail address_________________________________

Payment Options

2

q      My check is enclosed, payable to Child Guidance Clinic of Greater Waterbury totaling $____________

q      A matching gift form from my employer is enclosed.  

q      Please charge my credit card

          Amount________________________________

          Master/Visa_____________________________

          Expiration Date__________________________

          Name on Card___________________________

          Signature_______________________________

q      I’d like to include CGCGW in my will, trust or estate plans.  Please contact me.

q      I’d like to make a secure stock gift.  Please call me.

q      Please bill me

          q   Monthly

          q   Quarterly

          in the amount of $_____________ until my total contribution of $________________ is reached.

q      Please do not list my name in public acknowledgments of gifts.