Donor Form
Prefix	________________________________________________________
First Name	________________________________________________________
Last Name	________________________________________________________
Company	________________________________________________________
Address1	________________________________________________________
Address2	________________________________________________________
Ctiy, State, Zip	________________________________________________________
Daytime Phone	________________________________________________________
Email	________________________________________________________

Donor Name (as it is to appear in printed materials)

__________________________

	Check here if this is for a specific campaign
If you would like your donation to go towards a specific program or area please indicate here
________________________________________________________

If Donation is a Memorial or Honorarium, please fill out this portion
	In Memory of	________________________________________________________
	In Honor of	________________________________________________________

Send acknowledgement to
Name	________________________________________________
Address	________________________________________________
City, State, Zip	________________________________________________

Method of Payment
Circle one :	Check Enclosed	Visa	MasterCard	American Express	Discover
Card Number __________________________________ Exp. Date_________________
Name on Card ______________________ Signature ____________________________
Billing Address ______________________City, State, Zip _______________________
Daytime Phone Number _____________ Evening Phone Number __________________
Donation Amount $________________________________________________
Mail Checks To :
Wednesday's Child Benefit Corporation
11882 Greenville Ave., Suite 113
Dallas, TX 75243