Child and Adolescent Service Center

Donation Form

Text Box: ____  Option 1:  Mike Flood/Child and Adolescent Service                    Center Endowment for Children’s Mental Health,                                                                        Established 1999.   _____  Option 2:  Please use my gift toward programs and                   services.   _____  Option 3:  Choose Program or Service                                 _____________________________________________  

    _____      $75.00                    

    _____      $125.00  

                                                                                               

    _____      $250.00    

                                                                                              

    _____       $500.00  

 

    _____       $1,000.00

 

     _____       Other Amount (any size gift will help)

 

 

 

Name:_______________________________________________________

 

Address:______________________________________________________

 

City:_______________  State:_____ Zip:_________ E-Mail_______________

 

Would you prefer to pay for this contribution via:

 

_____   Check enclosed (please make checks payable to Child and Adolescent Service Center)

 

_____   Credit card

 

Credit Card Type:    _____Visa    _____MasterCard

 

Credit Card No._________________________________________________

 

Expiration Date:______________________

 

Signature:__________________________ Date:___________________

 

Please mail to the address below:

 

Child and Adolescent Service Center

C/O Finance Department

919 2nd Street N.E.

Canton, OH 44704

 

Questions? For more information on making a contribution, contact Jefferey D. Poulos, CASC’s Fund Development Director, at (330) 454-7917 ext. 130 or jpoulos@casrv.org.

 

Child and Adolescent Service Center is a 501(c)3 non-profit organization.  Tax ID:  34-1191950