____ My contribution of $ _____________ to the Kids' Chance Scholarship Fund is enclosed.

____$1,000     ____$500     ____$200     ____$100     ____Other

Name: __________________________________________________

Address: ________________________________________________

City: ___________________________________________________

State: ____________   Zip: ________________________________

Phone: _________________________________________________

Email: __________________________________________________

____ My employer is a matching gift corporation.

____ Please contact me to discuss my employer's involvement.

* Kids' Chance of Pennsylvania, Inc. qualifies as a charitable organization under the Internal Revenue Service Code Section 501(c)(3) and therefore, all contributions are tax deductible.