Please print this form and mail your check to:

Road of Life
Attn: Donations
35 E. Gay St. Suite 509 Columbus, OH 43215-3138

Date ___________________

Personal Information
My Name: _____________________________________________________________________

Address: __________________________________ Home Phone:(          )__________________

City/State/Zip _______________________________________________________________

Email____________________________________ (a receipt will be sent to the specified address)

Type of Donation

__ General Donation

__ A Gift in Memory of: _____________________________________________________                                                                                         (name of deceased)

__ A Gift in Honor of: _______________________________________________________
                                                            (name of individual)

Enclosed is my check in the amount of $_____________________ payable to: The Keren Emrich Foundation.

__ Please mail me my receipt U.S. mail

__ Please email me my receipt

Please send an acknowledgement card to

Name: _____________________________________________________________________

Address: __________________________________ Home Phone:(        )________________

City/State/Zip _______________________________________________________________

I would like the card to be signed: _______________________________________________                                                                                                            (name or names)