I WISH TO HELP BMHC

Name:__________________________________________________________________

Address:_______________________ City:___________________ Postal Code:_________

Enclosed is my donation of: _____ $25; _____ $50; _____ $100; $__________ other amount

I prefer to donate by VISA or MASTERCARD:

Credit card number:__________________________________ Expiry Date: ___/___

Cardholder's signature:______________________________________________________

I would like my donation applied to the following program/service:

[   ] general
[   ] medical clinic
[   ] dental clinic
[   ] Community Nursing Station
[   ] Kindred House
[   ] Women's Centre for Health
[   ] foot care clinic
[   ] other ______________________________________________

[   ] I would be interested in receiving more information about BMHC.
[   ] I would be intersted in receiving information about volunteering at BMHC.