Mail-in Contribution Form

Siloam is a primary and specialty health care clinic for the uninsured, underinsured and those who slip through the cracks of the traditional health care system due to financial, cultural and language barriers. Your financial support helps make high-quality, affordable health care available for thousands in need within the greater Nashville community.

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Donor’s Name (PLEASE PRINT)                                           (Area code) and phone number

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Donor’s Mailing Address (PLEASE PRINT)

Yes, I would like to provide a day of loving, compassionate health care to those in need.

O   I want to pledge a yearly gift of $2,400 (equals $300 per hour based on an eight hour clinic session)

O   I want to pledge a monthly gift of $500

O   I want to pledge a monthly gift of $250

O   I want to pledge a monthly gift of $100

O   I want to pledge a monthly gift of $50

O   I want to pledge a special gift of $__________

Thank you for helping “to share the love of Christ to

by serving those in need through health care.”

Please mail this form with your check to:

Siloam Family Health Center

P.O. Box 41687

Nashville , TN 37204

Siloam Family Health Center is a 501(c)(3) nonprofit organization. All donations are tax deductible to the extent allowable by law. For further information, please phone (615) 298-5406 ext. 117