The Rebecca Center for Music Therapy Pledge Form

Name:	_______________________________________________________________________
Address:	_______________________________________________________________________
City:	______________________________________ State:_________
Zip:	___________________
Home Phone:	________________________________
Work Phone:	________________________
Email:	______________________________________
I / We would like to pledge a minimum of $ _______________ to The Rebecca Center for Music Therapy. Payments will be made as follows:
$______________________ on _________________________ $______________________ on _________________________ $______________________ on _________________________ $______________________ on _________________________
Make checks payable to The Rebecca Center Mailing address: The Rebecca Center C/O John Carpente Molloy College 1000 Hempstead Ave. PO Box 5002 Rockville Centre, NY 11571
Telephone:	516-678-5000 ext 6643
Signed:	_________________________________________________ Date: ________________