Donation Form

Text Box:
PRINT THIS PAGE & MAIL WITH GIFT TO:

      Children’s Shelter of Blackstone Valley
     15 Gates Street
      Pawtucket, RI 02861

Your Name:________________________________

Address:___________________________________

City/State/Zip: ______________________________

Make Check payable to: CSBV
                   or
Please charge to my credit card:
____VISA   ____MasterCard      CC #_______________________
                                                        Exp. Date ____________
                                                       ___________________________
                                                         Signature

If you would like this donation to be a tribute,   please provide the       acknowledgement information below:

           _____ In Honor of                       ___ In Memory of

Name of individual: ____________________________________

Address:_____________________________________________

   City/State/Zip:________________________________________

   Occasion: ___________________, _________________________

Amount: _____________

   Thank you for your contribution. All donations are tax-
   deductible as provided by law; we are a 501 (c) (3) Corporation.

Please be sure to check with your employer; many companies
   will match charitable contributions made by their employees.

Your donation will directly benefit the children.

Text Box:
To contact us:
Phone 401 722 4626
FAX 401 727 2967
Email: childrensshelter@cox.net