Every dollar donated provides five dollars worth of free medical, dental, and mental health services. Your contribution stays in Cleveland and will directly benefit over 20,000 of our neighbors each year.
| [ ] | $500 | = | $2,500 | in services |
| [ ] | $300 | = | $1,500 | in services |
| [ ] | $100 | = | $500 | in services |
| [ ] | $50 | = | $250 | in services |
My check for $__________ is enclosed payable to The Free Clinic of Greater Cleveland
I will send $__________ each month
Please charge to my [ ] Master Card [ ] VISA
| Card Number | Expiration Date |
Authorized Signature
| City | State | ZIP Code |
Phone- (216) 721-4010
FAX- (216) 721-2431
E-mail- [email protected]
URL- www.thefreeclinic.org