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Your Gift of:

$6,000 - 50 Days of Care (includes 8 tickets)

$3,000 - 25 Days of Care (includes 4 tickets)

$1,250 - 10 Days of Care (includes 2 tickets)

$750 - 5 Days of Care (includes 2 tickets)

$525 - Salon and Spa for Four Participants (includes 1 ticket)

$300 - 3 Days of Main Street Connections (includes 1 ticket)

Other

$

Please enter a payment amount.

Yes, I would like to include the additional processing fee with my payment. Total amount:

I would like to make my payment anonymously.

Yes, I'd like to setup my donation to be a recurring gift. Interested in learning more before committing? Contact the Development Team at 336-721-3411. Frequency of Donations Monthly Quarterly Yearly Total # of Donations 2 3 4 5 6 7 8 9 10 11 12 24 36 48 60 Until Stopped Your first donation will occur today, and happen on this day until you have completed donations totaling .

To make a gift by check, please mail it to the address below:

Senior Services Inc. 
Attn: Development
2895 Shorefair Drive
Winston-Salem, NC 27105

Include an Honor/Memorial Designation to recognize someone special to you.

Matching Gifts | If your employer matches gifts, please let us know in the Additional Comments section below. Note that you will need to follow your employer's process to generate the matching funds distribution.

Your Contact Information

First Name *

Last Name *

Business Name

Email *

Phone

Address Line 1 *

Address Line 2

City *

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Zip *

Additional Patron Information

Some additional information will be needed from you:

• Please let us know how many plan to attend and utilize the tickets included with your patron gift*.
• Your mobile number is requested if you plan to attend the event. You will receive silent auction bidding instructions and additional information via text prior to and during the event.

*Note: the tax-deductibility of your patron gift cannot include the value of the tickets included with your selected level. If you prefer for your patron gift to be fully tax-deductible, please select '0' for How many plan to attend? and then purchase tickets separately by clicking here. Tickets are valued at $125 each. The online ticket link will close one week before the event. If you have questions, call the Development Team at 743-649-7019.

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As a patron, how many plan to attend? * 0 1 2 4 8 The field As a patron, how many plan to attend? is required.

50 Days of Care Patrons - Table Reservation Yes, I'd like to reserve a full table for my 8 admission tickets. No, I do not need a reserved table.

Mobile Phone Number (For Auction Purposes Only) The field Mobile Phone Number (For Auction Purposes Only) must be a phone number.

Honor/Memorial Information

In Memory of (honors an individual who has passed away)        In Honor of (marks a special occasion for a friend or family member)

In Memory of

Honoree Name

Special Occasion Birth Birthday Graduation Retirement Wedding Other

Other Occasion

If you would like us to notify someone of this gift, please provide full name and address for the individual that you want to be notified below:

Designated Contact Name

Address Line 1

Address Line 2

City

State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip

Designated Contact Email

Designated Contact Phone

Additional Comments

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