Donation Form

I am pleased to support Genesis Home with my gift of $__________

___$50     ___$250 ___$1,000

___$100      ___$500  ___$1,989 (1989 Society) 

             ___$3,500 (Leadership Circle)

¨ I would like to talk; please call me.

¨ I would like to learn more about the 1989 Society.

¨ I would like to learn more about the Leadership Circle.

This gift is in ¨ Honor of/ ¨ Memory of _____________________________

Personal message__________________________________________________

Please send an acknowledgement of this gift

to________________________________________________________________

Address_____________________________________  City_________________

State_________  Zip________

from______________________________________________________________

Address______________________________________  City________________

State_________  Zip_________

Email_______________________________Phone________________________

Preferred Salutation (for gift acknowledgment)___________________________________

                                                    -or- ¨ I prefer that this gift remain anonymous.

¨Check enclosed (payable to Genesis Home)

¨Credit Card ___ Mastercard    ___Visa    ____American Express

                Acct.#_________________________ V Code_____ Exp Date__/___

                Name on card_____________________________________

                ___ one-time gift    ___monthly (Loyalty Circle)

¨ I would like to learn more about the Loyalty Circle.

Thank You!

Please mail to:

Genesis Home

PO Box 25426

Durham, NC 27702