Donor's Name: _________________________________

Street Address: _________________________________

City: ___________________________________________

State: _____________________ Zip: _____________________

Donor's Phone Number: ____________________________________

E-mail (not mandatory) ___________________________________

Pastor's Name: __________________________________

Spouse First Name:________________________

Church Name: _______________________________________

Street Address: ____________________________________

City: ___________________________________

State: ___________________________________ Zip: _________________________

Phone # : _______________________

E-mail: ___________________________________________

Please tell us how you heard about Genesee Home? We want to be good stewards of Genesee Home funds and value your answer to this question so we
can best direct our marketing efforts. Please check all that apply:

Postcard from Kenton Beshore
Postcard from Ridge Burns
Postcard from Jill Briscoe
Postcard from Jeff Lilley
Letter from Jim West/Michael Brickley of The Pocket Testament League
Personal Reference - please give us their name ______________________________
Genesee Home Brochure
Genesee Home Website
Advertisement in Just Between Us Magazine
Other ________________________________________________

Please click below to send this information to Genesee Home and we will be in contact with you.
The Pastor will not be contacted until we have spoken with you.