CHAMPIONS DONOR CIRCLE COMMITMENT FORM

CHAMPIONS DONOR CIRCLE COMMITMENT FORM
I/We wish to join the inaugural Champions Donor Circle by making a three-year commitment to help the Lovering honor, respect, and advocate for the right of everyone to maintain freedom and choices regarding their own sexual and reproductive health.

Yes, I wish to join.
My/our commitment will be:

$5000/year for 3 years$7500/year for 3 years$10000/year for 3 years$15000/year for 3 years$25000/year for 3 years
Name
Address
Preferred Phone:
Format: (000) 000-0000.
Preferred Email
example@example.com
First Payment Instructions
I/We have made our contribution for 2024.

YesNo
Check enclosed or being issued from a fund / foundation for my first payment of
Enter the dollar amount. (Ex: $1,000 = 1000)
Future Payment Instructions:
I would like you to automatically bill this card for subsequent payments in 2025 and 2026.

YesNo
I would like to receive annual payment reminders in 2025 and 2026.

YesNo
I would like to make other arrangements for subsequent payments. (Our staff will contact you.)

YesNo
Acknowledgement
I/We are making this gift anonymously.

YesNo
I/We are making this gift anonymously. Please acknowledge this gift with the following name(s):
The gift is made in honor of:
The gift is made in memory of:
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Thank you for your consideration and support. Please contact Development Director, Mary Boisse-Barnes at mary@jglhc.org or 603-436-7588 with any questions. Tax ID: 22-2572590

Lovering Health Center - PO Box 456 Greenland, NH 03840 - 603-436-7588
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CHAMPIONS DONOR CIRCLE COMMITMENT FORM

First Payment Instructions

Future Payment Instructions:

Acknowledgement