Yes, I want to help thousands of infants and children in need by contributing to:

Emergency Infant Services

Enclosed is my gift in the amount of:

____$25 ____$50 ____$100 ____$250   Other$________

Name__________________________________________________________________

Address ________________________________________________________________

City________________________________________State________Zip _____________

Day phone: _______________________  Evening phone: __________________________

_____Check enclosed (Please make check payable to "Emergency Infant Services")

_____Visa   ______Mastercard

Contribution Amount:______________________________________________________

Account Number: ________________________________________________________

Expiration Date: __________________________________________________________

Name on Credit Card:_____________________________________________________

Signature: ______________________________________________________________

A receipt will be mailed to you.
Thank you for your generous support!