Adagio Health Donation Form
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Your gift will support and strengthen health care services and health education programs for teens, women, and families in your community.
Please print this form and return it to:
Adagio Health
960 Penn Avenue, Suite 600
Pittsburgh, PA 15222
Yes, I want to support Adagio Health with a gift of:
____ $1,000 ____ $500 ____ $250 ____ $100
____ $50 ____ $25 ____ Other ____________
____ My/our contribution is enclosed.
____ I want my gift to support: _______________________________________
____ I would like to include Adagio Health in my will. Please call me.
____ I would like to make a contribution of stock or life insurance. Please call me.
Please make your check payable to: Adagio Health
or ____ charge my VISA/Master Card (circle one) for $ ____________________.
Acct. # _______________________________ Expiration date ________________
Signature ____________________________________________________________
Name _______________________________________________________________
Street Address _______________________________________________________
City, State, Zip _______________________________________________________
Phone _______________________________________________________________
E-mail _______________________________________________________________
Remember, gifts to Adagio Health are tax deductible.
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