Mental Health Association in Orange County, Inc.

73 James P. Kelly Way
Middletown , NY 10940

Office: (845) 342-2400 Fax: (845) 343-9665

Donation Form  

A copy of MHA's latest annual report may be obtained, upon request, from Mental Health Association in Orange County, Attn:  Carole Lindsell or from the NYS Attorney General's Charities Bureau, Attn:  FOIL Officer, 120 Broadway, NY, NY  10271.

First Name:

 

MI:

 

Last Name:

 

Address:

 

City, State, Zip:

 

 

 

Phone Number:

 

Email Address:

 

         

   If you would like your donation to go to a specific program, please specify the program.        

        ________________________ 

   If you would like to find out more information on the Lucinda Sloan Mallen fund Click Here

Donation Amount:

 

 

Please check one:                       Donation ______ Memorial _____

(If you selected memorial please fill out the following information.)

 

Memorial Name:

 

Notification Name:

 

Notification Address:

 

Notification City, State, Zip

 

 

 

 

If you are making a Commemorative Gift, please indicate the occasion or reason for your donation.

  ___   Birthday

___   Anniversary

___   Graduation

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Additional Comments: ___________________________

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Please mail this form along with your donation to: 

Mental Health Association in Orange County, Inc.

73 County Highway 108
Middletown , NY 10940

Office: (845) 342-2400 Fax: (845) 343-9665

 

A copy of MHA's latest annual report may be obtained, upon request, from Mental Health Association in Orange County, Attn:  Carole Lindsell or from the NYS Attorney General's Charities Bureau, Attn:  FOIL Officer, 120 Broadway, NY, NY  10271.