Name/s:
Contact number(s):
Email Address:
Single $10 prepaid Couple $15 prepaid TOTAL Amount enclosed: $________
Payment enclosed: Cash: Cheque made out to Mansfield High School Chaplaincy:
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Please help to keep CHAPLAINCY at our school.
(NB Donations over $2 are tax deductible – Receipts will be issued.)
Donor’s Name: ________________________________________ Student’s Name: _________________________________________
Donor’s Address: _________________________________________________________________________________________________
Please tick q Cash q Cheque q Credit Card
Amount: $_______________
Credit Card Deduction
qOnce off q Monthly q Quarterly qHalf Yearly q Annually qOther: _____________________
Card issuer q Visa q Mastercard q Diner qAMEX
Card number: qqqq qqqq qqqq qqqq
Expiry date on Credit Card: _________ /_______(4 digits)
Name on card: _____________________________________________________________
Signature of Cardholder: _____________________________________________________________ Date: _____________________________
