Valentines for Life

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Yes! I want to support the Free Mammogram Program through the Whitley County Giving Circle for Women's Health and have either online via the stripe link or mail a $6 contribution in honor of each of the individuals listed. I understand they will each receive a special valentine notification of my contribution made in their honor.

After you submit your form, there will instructions on how to pay.
To ensure prompt delivery of the Valentines, deadline for submitting names is February 5th.

For additional information, please contact the Community Foundation at 260.244.5224.

Thank you for your support!

Instructions

You will not be able to save this application or come back to it later. If you close out your browser, you will need to start your application over.

Please review this form and have your responses ready. It is advised to prepare your answers in advance. You may also copy and paste your answers from Microsoft Word or other text based programs.

Contact Information

Name of Sender of Valentines*

Address*

City*

State, Zip*

Phone*

Email*

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Person being honored

Name

Address

City

State, Zip

Please upload a document listing any additional people you may want to honor.

If you have additional people to honor, upload a document with the additional information.

Please enter code.