ACH Payment by Check

Step 1: Please complete the following form.

Your Contact Information

First Name:

Last Name:

Company:

Phone:

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Your Home Address Information

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Purchase tickets for the April 6th Event:

Number of General Admission Tickets:	Unit Price: General Admission Ticket $200.	Subtotal:
Please select the person who informed you about this event.

I cannot make it to the gala but would like to make a donation, or I would like to make a donation in addition to my ticket purchase.

Donation Amount:

Subtotal:

In addition to my ticket purchase(s) I would like to make the following additional donation

Additional Donation:

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My Company Has a Matching Program for Charitable Donations

Total Donation:

Do you want this donation to be a Memorial Donation?
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In Memory Of:
Please acknowledge my donation to:
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Do you want this donation to be a in Honor of Someone?
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In Honor Of:
Please acknowledge my donation to:
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Step 2: Please write the check for the above amount to A Caring Hand.

Step 3: Please print this page and mail it, along with your check, to
            A Caring Hand
              2352 Legion St.
              Bellmore, NY 11710