NAMI West Central Indiana

You may give by telephone or by filling & printing this form out and mailing it with your check to the address below.

National Alliance on Mental Illness - West Central Indiana
P.O. Box 6232
Lafayette, Indiana 47903-6232
Phone: 765-423-6939 Fax: 765-423-6092

Name:

Address:

City/State/Zip:

E-mail Address: Phone:

I/we are making a gift to NAMI-WCI, totaling $

How your gift can help NAMI-WCI:

A gift of $120 ($10 per month) will provide educational materials for 3 family members in the 11 week Family-To-Family class.
A gift of $180 ($15 per month) will provide instruction and recovery support for 2 consumers over the 10 weeks of the Peer-To-Peer class.
A gift of $240 ($20 per month) will support the expense of one monthly Living with Mental Illness Forum.
A gift of $600 ($50 per month) 10 performances of the Mental Health Players as they work to eliminate the stigma of mental illness in our community.

My company has a Matching Gift Program. I will have either enclosed my employer form with this gift or will mail it shortly.
I would like NAMI-WCI to find out if my company has a Matching Gift Program (please fill out the following information).

Company/Location:

Select Payment type:

Cash
Check (made payable to NAMI-WCI)
Visa Mastercard Discover
Card#: Exp. Date (xx/xx):
(NAMI-WCI will not release your personal information to anyone.)

Signature:___________________________________________________

Print this form and mail or fax to NAMI-WCI at the above address.

Thank you for your generosity! You will receive a receipt for your gift shortly.

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