
		First Name:
		Last Name:
		Title:
		Company:
MAIL FORM Print this form. Please complete the following information and check appropriate contribution type and payment boxes. If you prefer to pay online through PayPal:		Address Line 1:
		Address Line 2:
		City:
		State/Province:
		Zip/Postal Code:
		Country:
		Phone:
		Fax:
		E-Mail:
Please note any additional Information or instructions on the reverse side.		IN MEMORIUM:
		IN HONOR OF:
		SEND NOTIFICATION:	^{INCLUDE COMPLETE NAME AND ADDRESS FOR ACKNOWLEDGEMENT.}

You can increase your contribution to Embracing the Child if your company has a Matching Gifts Program. Please send company form along with your contribution		MATCHING CONTRIBUTIONS:	^{PARTIAL LIST OF CORPS. THAT MATCH EMPLOYEE CONTRIBUTION}


PAYMENT METHOD:		CHECK OR MONEY ORDER	PAYABLE TO "EMBRACING THE CHILD"
		CREDIT CARD INFORMATION:	$_________
Mailing address: Embracing the Child 1818 Canterbury Road Abington, PA 19001 Thank you. RETURN TO WEB SITE
	*	NAME AS IT APPEARS ON CARD
	*	CARD NUMBER:
	*	EXPIRATION DATE:
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