Fill out and print this form to enclose with your donation.

I would like to donate to South Cove Community Health Center:
	My check of   $   is enclosed.   I would like to make a pledge of   $   over     years.   Please charge my Visa or Mastercard for   $ .
		Card #         Expiration date   Signature ___________________________

I would like to discuss other donation options with you. Please contact me as soon as possible:
	Name
	Address
	City	State   Zip
	Telephone	Fax
	E-mail

Print and mail this form to:

South Cove Community Health Center Attn: Division of Development 145 South Street, 2/F Boston, MA 02111 TEL: (617) 521-6715  FAX: (617) 521-6799