Donation Form

Support CHEER, Inc.

Thank you for your donation!
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Best Phone Number*

Area CodePhone Number
E-mail*
Do you or a family member receive ANY CHEER services? (Meals on Wheels, Adult Day Program, PASA, CHEER Membership, etc.)*

YesNo
Is this a donation for services provided?

YesNo
What CHEER Services are received by you or a loved one? (Check all that apply)

Meals on WheelsAdult Day ProgramPASA (Personal Assistance)CHEER MembershipOther
Which service would you like this donation applied to?

Meals on WheelsAdult Day ProgramPASA (Personal Assistance)CHEER MEMBERSHIPOther
Is this donation in memory or honor of someone?

YesNo
Who is this in memory or honor of?
Please apply my gift to:

Unrestricted (where the need is greatest)Personal Assistant CareMeals On WheelsTransportationAdult Day ProgramCHEER CentersOther

My Donation

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Credit Card

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Support CHEER, Inc.