Please print this form before filling it out.  Mail it with your donation to: Hospice Volunteers: Center for Grief and Loss in Mid Coast Maine, 45 Baribeau Drive, Brunswick, ME 04011.  Thank you for your contribution.

I want to support Hospice Volunteers' continued expansion to meet the growing needs of our community.

Name: ___________________________________________________________________

Address:_________________________________________________________________

City:__________________________________   State:___________   Zip:_____________

Telephone: (_____)_______________________
 

____ I have included Hospice Volunteers in my will (we would like to thank you).

____ Send me information about ways I can include Hospice Volunteersin my estate planning.
 

Level of Giving:

___$35  ___$50  ___$100  ___$250  ___$500  ___$1,000  ___$5,000  ____________Other

In memory of:_____________________________________________________________

In honor of:_______________________________________________________________

• Make your check payable to: Hospice Volunteers
• We are a 501 (c)(3) tax-exempt organization. Donations are tax-deductible.

Thank you for your generous donation!

All services provided by Hospice Volunteers are free.  We depend upon United Way funding,
memorial donations, bequests, individuals and businesses for contributions.

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