Mission Medical Clinic 2125 E LaSalle St. Colorado Springs, CO 80909 (719)219-3402

 

 
 
  Check Donation Form 

I would like to donate the following amount $___________________ 
 
Circle one:      Monthly          Single             Donating by Check
 
Please mail your check to the address above.
 
Please provide the following information in full:
 
Circle Your Preferred Title:       Ms      Mrs      Mr       Dr    Other_______  
 
 
First Name: _____________________________
 
Last Name:_____________________________
 
Mailing Address:
 _____________________________________________________________________
 
City_____________________ State ___________ Zip Code _________________
 
Country ____________ Email ___________________________________________
 leave blank if you do not want to receive email updates
 
Age (circle one) 18-29 30-45 46-54 55-64 65+
 
Church Home__________________________________________________________
 
Occupation___________________________________________________________
 
 
Daytime Phone: _____________________ Evening Phone _____________________
           

(719) 219-3402

 

Our Mission: To Heal the Sick in the Name of Jesus Christ
Because we believe - we care. Because we care - we do.