Haiti Disaster Relief Fund

Contact Information * required

First Name *

Last Name *

Contact Phone *

Home Phone

Work Phone

Mobile Phone

Email *

Street *

City *

State *

Postal Code *

Your Church

Please tell us your church (i.e. Peace Lutheran, Lombard, IL) or church affiliation (Lutheran, Catholic, UCC [or none if applicable]). We use this for tracking purposes only. We just like to know who and where we are reaching. Thank you.

Are you a Thrivent Member?

Yes

Enter a Dollar Amount in the "Quantity" Blank below...

If you choose to use the Pull-Down Arrow, you may select from the list to choose a Dollar Amount
- or - Type the Amount into the box

Quantity = Increments of $1.00.

If you have any questions, please call us at 866-455-6466

I Understand and Agree

Total

Quantity
Price Per Ticket	$ 1.00
Pay With
TOTAL	$ 0.00