Donation Form

 Thank you for making a contribution to Brandywine Counseling.

Please print and complete this form and mail it with your contribution to: 

 

Brandywine Counseling

2713 Lancaster Avenue

Wilmington, DE 19805

Name:_________________________________________________________________

Address:_______________________________________________________________

City: ______________________________ State: __________ZIP: _________________

Phone:___________________________   E-mail: ______________________________

I have enclosed a check  made payable to Brandywine Counseling for:

¨ $500        ¨ $100        ¨ $50        ¨ Other __________

¨ In honor of: _____________________________________________

¨ In memory of: ____________________________________________       

____ The Capital Endowment Fund

____ A specific program: __________________________ 

____ HIV Prevention Services

____ Unrestricted

¨ I would like my gift to be anonymous.

Tel – (302) 656-2348                                                                                Fax – (302) 656-0746                                                 Web – www.brandywinecounseling.org