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Please print, complete, and mail this form with your check or credit card information.

Covenant House
Times Square Station
P.O. Box 731
New York, NY  10108-0900

Code: MCHKNZ

Name (circle one) Mr./ Ms._____________________________________________

Address ___________________________________________________________

City __________________________ State/Province ________ Zip ____________

Country _______________ E-mail ______________________________________

I am making a gift of:   

[ ] $25    [ ] $50    [ ] $100    [ ] $250    [ ] $1000    [ ] Other $_______________

Make check payable to Covenant House. To make your gift by credit card, fill out the information below:

Name (as it appears on card) __________________________________________

Credit Card Number _________________________________________________

Expiration Date __________ (MM/YY)

Credit Card (circle one): MasterCard | VISA | American Express

Signature __________________________________________________________

This gift is: _____ in honor of   _____ in memory of

Name _____________________________________________________________

Send acknowledgment to:

Address ___________________________________________________________

City __________________________ State/Province ________ Zip ____________

Country _______________ E-mail _______________________________________

Please complete this form and mail it to:

Covenant House
Times Square Station
P.O. Box 731
New York, NY  10108-0900

Code: MCHKNZ