HORSEPOWER THERAPEUTIC LEARNING CENTER

CONTRIBUTION FORM

Please print, complete, and mail or fax to the address below.

Contact Information (Please Print):

Title:_________ First Name:______________ MI:_______ Last Name:___________

Address:_____________________________________________________________

City:______________________________ State:_________ Zip:________________

Home Phone:________________________ Cell:______________________________

E-mail:______________________________________________________________

Company/Organization Name:_________________________________________________

Title:_____________________________ Matching Gift Company? Yes No Unsure

Address:________________________________________________________________

City:_____________________________________ State:_______ Zip:______________

Office Phone:__________________________ Cell:______________________________

E-mail:_________________________________ Fax:_____________________________

Spouse Name:_________________________ Company Name:______________________

Office Phone:________________________ Title:_______________________________

I prefer to be called/e-mailed at: Home Office

This gift is: (Circle One) In Honor Of In Memory Of______________________

Please notify; Name_________________________

Address_______________________

_____________________________

Enclosed is my/our gift of $_________________ Check payable to HORSEPOWER, Inc.

Please charge my gift of $_______ to the credit card below:

Credit Card Type: (Circle One) Visa MC Discover American Express

Card Number: _______________________________________ Exp. Date:_________

I/We pledge a total gift of $_______, payable in quarterly monthly installments.

( Please send me reminders)

Please contact me about:

Volunteer Opportunities Corporate Sponsorships

Sponsoring a Student Rider Including HORSEPOWER in my will/estate

Donating a horse or other in-kind items plans.

THANK YOU! Please return to:

HORSEPOWER Therapeutic Learning Center

8001 Leabourne Road, Colfax, NC 27235

Attn: Tim Clifford, Director of Development

tim@horsepower.org Phone (336) 931-1424 Fax (336) 931-1425

8001 Leabourne Road, Colfax, NC 27235