DONOR FORM

I understand that my donation shall be placed into an account at a Philadelphia credit union and that it shall be used primarily to enroll lowest-income uninsured.
I understand that administrative costs are capped at twice the livable wage.
I understand that PhilaHealthia shall be governed by bylaws found at healthdemocracy.org/bylaws

NAME: __________________________________________________________________

ADDRESS: _________________________________ CITY _______________ STATE ___ ZIP ______

EMAIL ______________________________________ (optional) PHONE __________________________ (optional)
(you will be notified by email whenever the number of new members enlarges their coverage)

DONATION $__________

MAIL TO:
700 Carpenter Lane
Philadelphia, PA 19119

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