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:
City   State   Zip
Telephone Fax

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