Will You Be a Samaritan Partner?

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What level will you be partnering at? *

Legacy Samaritan Partner ($10,000)

Advocate Samaritan Partner ($5,000)

Neighbor Samaritan Partner ($2,500)

Friend Samaritan Partner ($1,000)

I will be sending my partnership fee in the following way: *

I will be mailing a check

I've already paid at the <a href="https://www.goodsamaritaninn.org/donate-2"> donate page </a>

Other - Please call 217-429-1455 to discuss