To Make a Cash Donation to
LIFE Center for Independent Living:

Your cash gift strengthens our ability to assist people with disabilities to live independently. Print this form and mail it to LIFE Center with your check, made payable to LIFE Center for Independent Living.

Here is my gift of:

$25____ $50____ $100____ $500____ $1000____ Other____

Date: ____________________

Name: ____________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Telephone: (       ) _________    (Circle or highlight one)     Voice     TTY     FAX

E-Mail: __________________________________________________________


I would like to receive the following information: (Circle or highlight what you want)

Newsletters
Event and Workshop Announcements
Advocacy Updates
Annual Reports

Preferred format for print materials: (Please check one)

____ Regular print
____ Large print
____ Braille
____ Diskette
____ Audiotape
____ E-mail

Preferred method of receiving mail:  (Please check one)

____ Mail
____ E-Mail


Please fill out this coupon and mail, with your donation, to:

LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704

Thank you for your support of LIFE Center for Independent Living!