Citizens Health Advisory Council

Thank you for your generous support! Please complete the form below and mail it in with your donation.

General Information

Full Name
Company
Mailing Address
City
State
Zip
Home Phone
Daytime Phone
E-mail Address

For Citizens Health Advisory Council use only. Your privacy is guaranteed.
We will never give, lease or sell your personal information.

Donation amount ~

I want to contribute to CHAC La Plata $

I want to contribute to the Non-profit Voucher Program (Dental Care) $

Please send me a receipt for my contribution

Community Foundation Serving Southwest Colorado
PO Box 1673 | Durango, CO 81302
Financial management is provided by the Community Foundation Serving Southwest Colorado.

Make your VOICE Heard!

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Current (LWV) Federal, State and Local
Healthcare Information