Name ________________________________________________________________________ Org/Company__________________________________________________________________ Street Address _________________________________________________________________ City, State & Zip ________________________________________________________________ Home Phone _____________________________ Work

Phone ___________________________ E-Mail Address _________________________________________________________________

Please complete this form & return by August 3, 2012 to: For more information contact Marcia Jones at:

BHcare Back to School Program P.O. Box 658, 435 East Main Street Ansonia, CT 06401 Attn: Marcia Jones

mjones@bhcare.org or call 203-736-2601, ext. 327

Due to the confidentiality policy of BHcare domestic violence programs, the identity of the child you adopt as part of the Back-to-School Program will remain anonymous. Thank you for your understanding!

Please indicate which option you would like to participate in by checking the appropriate Program Option(s) in the boxes below.

Option A - I wish to adopt ______ child(ren).

I prefer to shop for the child(ren).

Please note: Once this form is received by our office, your childs information will be mailed to you with his/her sizes and delivery instructions.

Option B - I wish to purchase gift certificates for back-to-school clothing and/or supplies for
children currently receiving services from the Center for Domestic Violence Services (CDVS) or for those serviced throughout the school year. (Please enclose the gift certificates with this completed form. )

Option C - I wish to make a monetary donation to the Back to School Program.

All monetary

donations will be used to shop for a child currently receiving domestic violence services. Please note, if additional donations are received beyond the current need, these funds may be used to meet needs of domestic violence clients throughout the year.. Please make checks payable to Birmingham FoundationBack to School

Mail donations, along with this form, to the above address.

For Office Use Only: Family _______ Ref # _________