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Reunion with a Cause - Donation Form

I would like to share the gift of health by pledging my support to the

2015 Reunion with a Cause.

(Bolded fields are required.)

Please indicate below how your donation should be listed.

If you are part of a team, please note your team name:

Street Address:
Postal Code:
E-mail Address:
Telephone #:
Donation Amount
For each $10 donation we will decorate a luminary and put the name of your
friend(s) or loved one(s) on it and place it on the track at the event.

Double or triple your gift for Genesys cancer patients if your company has a matching gift policy. If so, contact your human resources department for a matching gift form and send the completed and signed form to: Genesys Health Foundation, One Genesys Parkway, Grand Blanc, MI 48439. We will do the rest.

If you would like the acknowledgement of this donation sent to a different address than the one above, please provide that name and address here:

Credit Card Number:
Expiration Date:Card Type
Security code: (on back of card)

Visa,Mastercard, Discover, Amex

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One Genesys Parkway • Grand Blanc, Michigan 48439 • 810-606-5000
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