Contribution Form
We appreciate your decision to support KMHS with your gift. Thank you for helping us change the face of mental illness to wellness.

Please complete all required fields below. Required fields are highlighted and marked with an asterisk (*). When designating your gift, please enter the amount of each designation. Your total will appear below.

How would you like KMHS to use your gift?  
  KMHS Program: $ .
  KMHS Endowment $ .
  KMHS General Operations $ .
  Other: $ .
Contact Information  
Title:
*First Name:  
*Last Name:  
Joint Gift:
(Name of spouse/partner)
*Address 1:  
Address 2:
*City:  
*State:
*Zip Code:    
*Phone: ()-    
Email:
May we add you
to our Mailing List?
Tribute Information If you wish to make your gift a tribute to someone special to you, please provide the name of the person you wish to honor and contact information for anyone who should be notified of your generosity. The gift amount will not be disclosed.
In Honor of:
Occasion:
(e.g.,Birthday,Anniversary)
In Memory of:
Please Notify  
Name:
Relationship: (Relationship to person in whose honor or memory this gift is made)
Mailing Address:
City:
State:
Zip Code: (Minimum 5 digits)
Payment Information  
*Contribution Amount: $ .
*Credit Card Type:    
*Credit Card Number:    
Enter your credit card number without spaces or dashes.
*Expiration Date (MM/YYYY):  
*Name:
(as it appears on card)
 
Company Name:
(Corporate Credit Card donations)
Matching Gifts Your employer may match your contribution. If so, please consider requesting a match on your gift to Kitsap Mental Health Services.
 
  Please send your company’s matching gift form to:
   Kitsap Mental Health Services
   Attn: Development and Community Relations
   5455 Almira Drive NE
   Bremerton, WA 98311
How did you find out
about the website?
(optional)
 
  Referred by solicitation letter
  Referred by friends/family
  Browsing the web
  Newspaper article/advertisement
  Other:
 
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