To Make a Monthly Gift to
LIFE Center for Independent Living
Your cash gift strengthens our ability to assist people with disabilities to live independently. You may wish to make a monthly pledge. You can change or cancel your monthly contribution at any time. Print this form and mail it to LIFE Center with your check, made payable to LIFE Center for Independent Living.
I pledge $_____ each month.
____ Enclosed is my first month's contribution.
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
LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704
Thank you for your support of LIFE Center for Independent Living!