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| Oliver Foundation Donor Form | |
Name: |
_________________________________________ |
| Address: | _________________________________________ |
| _________________________________________ | |
| City: | _________________________________________ |
| State: | _________________________________________ |
| Zip: | _________________________________________ |
| Home Phone: | _________________________________________ |
| Cell Phone: | _________________________________________ |
| Alt. Phone: | _________________________________________ |
| E-mail Address: | _________________________________________ |
| This Gift Honors: | _________________________________________ |
| ___ Yes ___ No | I wish to to be recognized as an Oliver Foundation donor in printed materials. |
| Payment Information | |
| Signature | __________________________________ |
| Donor Level: |
_____$25-$249 _____$250-$999 _____$1,000-$2,499 _____$2,500-$4,999 _____$5,000-$9,999 _____$10,000 and above |
Help Prevent childhood Obesity, Support the Oliver Foundation