Please print out, complete, and mail this form with your check or money order to:

Youth Villages
P.O. Box 341154
Memphis, TN 38184-1154

Thank you for your support!

Name _________________________________________________________________

Street ________________________________________________________________

City ___________________________________ State _____ Zip ________________

Telephone ______________________

E-mail _________________________________
(must have if electing to receive Donor E-Mail)

Amount Donated ________________________________________________________

Please check here if:

_____ You prefer not to be listed publicly as a Youth Villages Supporter
_____ You prefer not to receive the bimonthly Donor E-Mail