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Donation Form  Donation Form




Contributor Information:

Name: ____________________________________________________________________

Mailing Address: __________________________________   Phone: __________________

City: ____________________________________ State: _______ Zip: _________________

Email: ____________________________________________________________________

Enclosed is my gift in the amount of: $___________________

Please make checks payable to Rockport-Fulton Good Samaritans, Inc.

This gift is given:

£ As an unrestricted gift

£ As a contribution to Kid Care

£ As a contribution to Christmas Baskets

If this donation is a gift or memorial: (please choose one)       

£ In Memory of: _________________________________

£ In Honor of: ___________________________________

Please send a notification to person listed below.

Name: ____________________________________________________________

Mailing Address:  ___________________________________________________

City: ____________________________________ State: _______  Zip: ________


£ I would like more information about Good Samaritans.

£ I would like to be called about volunteering.

£ I would like a speaker for my club or organization.

Group name: _______________________________________________________

Group contact person: ___________________________   Phone: _____________



Please return this form to:

Rockport-Fulton Good Samaritans, Inc., 507 South Ann Street, Rockport, Texas 78382


Thank you for your contribution.

All contributions are tax deductible to the extent permitted by law.

EIN#: 742592626