Donation Form

Yes, I would like to support children with learning differences.

Please download this form and mail to:

4R's Education Centre (Soc.)
581 McPhee Avenue
Courtenay, BC
V9N 2Z7

Enclosed is my tax-deductible gift of:
[   ]$35     [   ]$50     [   ]$100     [   ]$500     [   ]Other $_____

Please send an income tax receipt to:
[   ]Mr.     [   ]Mrs.     [   ]Miss     [   ]Ms.     [   ]Other

Name (please print in full, including middle initial(s)):	___________________________________
Address:	___________________________________
City:	___________________________________
Province/State:	___________________________________
Postal/Zip Code:	___________________________________
Phone:	___________________________________
E-mail:	___________________________________

(Receipts for less than $20 will be issued upon request only).

[   ] I would like my gift to remain anonymous.

[   ] I would like to receive a copy of 4R's most recent newsletter.

Charity registration number BN 89887 0530 RR0001

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