Support Self Regional Healthcare

Please print out, complete, and mail this form with your check or money order to:

Self Regional Healthcare Foundation
1325 Spring Street
Greenwood, SC 29646

Thank you for your support!

Name _________________________________________________________________

Street ________________________________________________________________

City ___________________________________ State _____ Zip ________________

Telephone ______________________

E-mail _________________________________
          (must have if electing to receive Donor E-Mail)

Amount Donated ________________________________________________________

Please check here if:

_____ You prefer not to be listed publicly as a Self Regional Healthcare Supporter
_____ You prefer not to receive the bimonthly Donor E-Mail