Belarus & Baltics   
I would like to become a 'Young Life Belarus & Baltics' Partner
Fill out this form then Post to: 214 Melrose St, Rochester NY 14619 or phone: (585) 643-5991
Your Donation
  $ 50
  $ 75
  $ 100
  $ 150
I would like to donate this amount to Young Life
  each month
  as once off contribution
Donations to Young Life are Tax Deductible
Your Details
Please add me to your donor mailing list for future updates
Payment Method
Account X 701- Belarus & Baltics
Please debit my Credit Card
Visa Amex Mastercard Discover      
Card no.
Name on Card Expiry Date
Signature ______________________________ Date: ___/___/___  
Check / Money Order
I enclose a check / money order made payable to Young Life
Direct Debit Payment (for monthly contributions)
Name of Bank  
Account name First Payment
Account no.

Electronic Funds Transfer: I authorize my bank to transfer the above stated amount from my account in accordance with the terms and conditions stated below. Please transfer my monthly amount on the

10th 25th of each month


Terms & Conditions: 1. Enter your personal information in the upper portions of this response form. Make sure you sign your name, and include the gift amount and todays date. 2. Select whether you wish to have your gift deducted from your bank account or if you would rather use your credit card. Complete the requested information above and 3. Include: A check for your current commitment, so your giving will not be interrupted, and a void check to provide us with the requested banking information for electronic transfer.

The first transfer will take place 30-45 days after receipt of this application. If you choose electronic transfer from a savings account please state so and attach a deposit slip for that account to this form. You will receive a letter confirming your participation in Young Life's program. Each month the transfer occurs automatically and the record of giving appears on your bank account or credit card statement. Young Life will continue to send you receipts for your tax records. If at any time you wish to discontinue your giving contact YoungLife Belarus in the first instance on (585) 643-5991; or write to 214 Melrose St, Rochester NY 14619. Young Life Service Centre details (719) 381 1985; PO Box 520, Colorado Springs CO 80901-0520.

Signature ______________________________ Date
Signature ______________________________ Date