Donation Form

Please print this page and, when completed, mail it to:
Director of Development
Bazelon Center for Mental Health Law
1101 15th Street N.W., Suite 1212
Washington D.C. 20005

Yes! I want to help end discrimination against children and adults with mental disabilities and enable them to participate fully in community life.

Here is my tax-deductible gift to the Bazelon Center for Mental Health Law in the amount of $__________.

Title: __ Mr. __ Ms. __ Mrs. __ Miss __ Dr. __ Prof. __ Rev. __ Other______

Name: _________________________________________________________

Suffix: __ M.D. __ Ph.D. __ J.D. __ Esq. __ M.S.W. __ Other_______

Organization:____________________________________________________

Address:________________________________________________________

_______________________________________________________________

City: ________________________________ State: __ Zip: _______________

Phone:__________________________________________________________

Email: __________________________________________________________

You may list my name as a donor. OR Please list me as "Anonymous."

About your contribution:

My check payable to Bazelon Center is enclosed.
OR
Please charge my   MasterCard   Visa   AmEx

card # __________________________________ exp. date ___/___

security code__________

My gift is $500 or more. Please enroll me in the Bazelon Society.

This is a pledge, to be fulfilled in ____ payments of $______ on the following dates:

____________________ month       year ____________________ month       year ____________________ month       year

____________________ month       year ____________________ month       year ____________________ month       year

My gift is

in memory of _________________________________________________
in honor of the
    Anniversary       Birthday
    Marriage           Graduation
    New baby         Promotion
    Mother's Day     Father's Day
    Other occasion: _______________________________________________

of ____________________________________________________________

Please send a special card announcing the gift (but without its amount) to:

Name: _________________________________________________________

Address:________________________________________________________

_______________________________________________________________

City ________________________________ State ____ Zip _______________

Please also send cards announcing the gift to:

Name: _________________________________________________________

Address:________________________________________________________

_______________________________________________________________

City ________________________________ State ____ Zip _______________

Name: _________________________________________________________

Address:________________________________________________________

_______________________________________________________________

City ________________________________ State ____ Zip _______________

Questions about contributing to the Bazelon Center? E-mail the Development Department, or call 202-467-5730 ext. 124.

Thank you very much for supporting the work of the Bazelon Center for Mental Health Law!