Kokolulu Cancer Retreats Donation & Pledge Form

Yes, I want to support Kokolulu Cancer Retreat Programs with a gift of

 r$500   r$250   r$100   r$50  r$ _____________
COME TO HAWAII!
attend a:
personal retreat


Kokolulu Farm and Qigong Center is built on the vision of creating a peaceful, healing environment that places a focus on the care of the whole person using the intention of Mind/Body/Spirit connections.

AFTER A DARK NIGHT
DO SOMETHING DIFFERENT
 YOU DESERVE IT!

A problem cannot be solved with the same mindset that created it.
A Einstein


Next
Cancer Group Retreat
March 11-15  2008
Sign Up Now

KoKoLuLu
The "Gold Standard" in  Cancer Retreats



Your Name______________________________________________________________

Address_________________________________________________________________

City _____________________________________ State ___________ Zip ___________

Email___________________________________________________________________

Phone__________________________________________________________________
 My gift is enclosed

My employer, ____________________________________________ , will match my gift.

I prefer to pledge:
  $________ monthly
  $________ quarterly
One-time pledge of $____________ to be paid on _____________ (date)
(Reminder slips will be sent for your convenience.)
Total pledge amount: $__________

Memorial and Honor Gifts
This gift is:
 In honor of_____________________________________________________________

 In memory of ___________________________________________________________

Send honor/memorial acknowledgement to:
Name_________________________________________________________________

Address _______________________________________________________________

City ___________________________________ State _________ Zip ______________

If paying by check:
Please make check payable to North Kohala Community Resource Center (or NKCRC) with Kokolulu Cancer Retreat Programs in the memo portion of your check.

If paying by credit card:
Type of card _____________________(Visa or Master Card only)
Card Number________________________________

Expiration date: _______________

The Card Security Code (CSC) 3 or 4 digit numbers (usually printed on the card's back)  ____________

Name on the card: ________________________________

Billing address of the card___________________________________________________
______________________(mailing address, city, state, zip code).

Your signature: _____________________________________
Your information is confidential and not shared
PLEASE FAX or MAIL IN THIS COMPLETED FORM
Mail to:
NKCRC
POB 2
Hawi, HI 96719
Fax to: (808) 889-5527

Your donation is tax deductible to the extent allowable by law.
North Kohala Community Resource Center is a nonprofit 501(c)(3) organization
(IRS #02--055-3251) and is the fiscal sponsor for Kokolulu Cancer Retreats Program.
If you have questions, please contact Christine at the Resource Center (808) 889-5523 or Kokolulu  (808)889-9893 or lew@cancer-retreats.org