Please print this form

CrossRoads: Sexual Assault Response & Resource Center*

Yes, I want to help and prevent sexual violence!

• I am enclosing my gift in the amount of:
  • $1000
  • $500
  • $250
  • $100
  • $50
  • Other $
• Name
• Phone
• Email
• Address
• City, State & Zip
• This gift is in honor of
• In memory of
• Please send acknowledgement to
• Address
• City, State & Zip
• 
  Please contact me about volunteer opportunities

*We are a 501(c)(3) non-profit corporation.
Your gift may be tax deductible according to the IRS guidelines.
Please send your check (payable to CrossRoads) to P.O. Box 673 Burlington, NC 27216.