To donate by mail please complete this form and mail to:

VNA Health at Home, Inc. 

27 Siemon Company Drive 

Watertown, CT 06795

I/we would like to support VNA Health at Home with a tax-deductible donation of:

£$500          £$250         £$100          £$50          £$25          £Other ______

Name: ___________________________________________________________________

                   (Please list as you wish your name(s) to appear in donor listings)

Address: _________________________________________________________________

Phone: _________________________ Email: ____________________________________

Please use this gift to fund:  £ Home Care    £ Hospice    £ Where Needed Most

£ Enclosed is my check made payable to VNA Health at Home

£ Please charge my £ MasterCard   £ VISA

Card No.: ________________________________________ Expiration: _______________

Signature (required for charges): __________________________________________________

£ I wish to make this gift: £ in memory of / £in honor of: _________________________

                                                                                                        (Please print name of honoree clearly.)

£ Please notify the honoree / honoree’s family of my gift.

      (To protect the privacy of all donors, amounts of individual gifts are not shared.)

      Name(s):  __________________________________________________

      Address:  __________________________________________________

£ I wish to remain anonymous. Please do not publish my name.       

£ Enclosed is my employer’s matching gift form.