To make a donation to our Annual Fund please print out this donation form and mail it with your check made payable to the Glaucoma Service Foundation or credit card authorization to:

Katharine Woodward
Glaucoma Service Foundation to Prevent Blindness
Wills Eye Institute
840 Walnut Street - Suite 1130
Philadelphia, PA 19107-5598

Your contributions are greatly appreciated. THANK YOU!

Donation Amount: $_____________

In memory of:  _________________________________________________
In honor of: ___________________________________________________

Please notify:__________________________________________________

Street Address: ________________________________________________

City: __________________________________ State: ____ Zip: _________

Your Names (S): _______________________________________________

Street Address: ________________________________________________

City: _________________________________ State: ____ Zip: __________

Phone: ___________________ E-Mail: _____________________________

Please make checks payable to: Glaucoma Service Foundation.

Please charge my credit card the above-noted dollar amount.

Card:   __ American Express   __ Visa   __ MasterCard

Number: ______________________________________ Exp. Date: ______

Signature: ____________________________________

___ Please check if you want a receipt

The Foundation has 501(c)(3) Internal Revenue Service status, making it eligible to receive tax-deductible gifts.

The official registration and financial information of the Glaucoma Service Foundation to Prevent Blindness may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.