| ________________________________________ Name of Congregation/Group |
______________________________________ Name of Contact Person |
| ________________________________________ Address |
______________________________________ Home Address |
| ________________________________________ City/State/Zip |
______________________________________ City/State/Zip |
| ________________________________________ Daytime Phone |
______________________________________ Daytime Phone |
| ________________ Tools & Blanket Date |
________________ Amount $$$ Raised |
___________________________ Where $$$ Sent |