Group Psychotherapy Foundation Contribution Form

Group Psychotherapy Foundation Contribution Form

Donate Now Online OR

Please print out this form and mail it to:

Group Psychotherapy Foundation
25 East 21st Street, 6th floor
New York, NY 10010

I support the work of the Group Psychotherapy Foundation and wish to join the Founders Club as a:

Contributor $25 $50 $100 $150 Other $___
Donor ($150 - $499)
Supporter ($500 - $999)
Guide ($1,000 - $2,499)
Sponsor ($2,500 - $4,999)
Explorer ($5,000 - $9,999)
Sustainer ($10,000+)

My contribution of $________ is to be applied as follows:

To be determined by the Group Psychotherapy Foundation
To be designated for the following Special Fund: ___________________________________

AWARDS

Alonso Award Fund
Aaron Stein Memorial Award Fund

SCHOLARSHIPS

Donated Annual Meeting Scholarships

Anne Alonso Scholarship Fund

Donald T. Brown Memorial Scholarship Fund
Josephine M. Cunningham Tervalon Scholarship Fund
Durkin-Glatzer Scholarship Fund

Mary M. Tanenbaum Scholarship Fund
Ruth Hochberg Scholarship Fund

Susanne Jensen Scholarship Fund

Saul Scheidlinger Scholarship Fund

PROGRAMS

Education Fund:

   Anne Alonso Endowment Fund

   Louis R. Ormont Endowment Fund

   John Price Memorial Fund
   Albert E. Reister Memorial Fund
   Perry Roth Memorial Fund

Mitchell Hochberg Memorial Public Education Fund
Research Fund
S.R. Slavson Memorial Lectureship Fund

Name
Address
Phone

My check is enclosed. Please deduct my contribution from my credit card.
Credit card
Account number
Expiration date
Signature	________________________________________

Contributions to the Group Psychotherapy Foundation are tax-deductible as provided by law.

Thank you for your support!