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Please fill out the information below. Your donations are private and secure.
 

 
Any contribution may be given as a Memorial/Honorarium. See information below.

Become a “Gift of Life” Guardian Angel
 
$50,000 Celestrial Angel
$20,000 Heavenly Angel
$10,000 Grand Benefactor
$5,000 Underwriter
$2,500 Patron
$1,000 Sponsor
$100 Pledge of $100 a year for ten years*
 
All Guardian Angels are automatically enrolled as Charter Members.
 
Annual Membership
 
$100 Charter
$50 Patron
$35 General
 
Special Gifts
 
I do not wish to become a member at this time, but I would like to send a donation so that someone may receive the “gift of life.”
 
$10  
$25  
$50  
$100  
Other  $     
 
 
Cancer “Heroes”
 
I wish to be recognized as a breast cancer survivor.
I wish to be recognized as a prostate cancer survivor.
I wish to be recognized as a testicular cancer survivor.
 
The Julie Rogers “Gift of Life” Program allows you to choose how you would like your gift directed:
 
I would like my gift to support BOTH the Breast and Prostate Health Programs.
I would like my gift to support the Breast Health Program.
I would like my gift to support the Prostate Health Program.
 
 
Memorials / Honorariums
 
My membership contribution or special gift is:
 
In memory of: 
Your relationship to deceased: 
Or
In Honor of: 
Commemorating: 
(Indicate birthday, anniversary, speedy recovery, or other special occasion.)
Your relationship to honoree: 

 
 
Send Memorial/Honor Card To:
 
Name:
Address:
City:
State:
Postal Code:

 
 
My Information:
Preference: 
Title   Other: 
Name:*
Address:*
City:*
State:*
Postal Code:*
Preferred Phone
Fax:
Email:*
 
*An individual or company pledging $100 for 10 years is designated as a Guardian Angel only for the year in which the pledge is made. Thereafter, the $100 annual payment goes toward the pledge and charter membership.
 
 
*Required  
 
 
 
 
 
SERVING ALL OF SOUTHEAST TEXAS, INCLUDING JEFFERSON, ORANGE, AND HARDIN COUNTIES
(409)833-3663  |  (877)720-GIFT(4438)  |  (409)833-2662 fax
Julie Rogers "Gift of Life" Program   2390 Dowlen Road, Beaumont, TX 77706
2009 Julie Rogers "Gift of Life" Program. All rights reserved