First Name:    Last Name:

Street Address:

City: State: ZIP Code:

Home Phone:   

Business Phone:

e-mail address:

Yes!  Sign me up!  I am interested in helping in the following way(s):

Business Guidance Committee:             Member     Chairperson

Fundraising Committee:                         Member     Chairperson          

Health Education Committee:                 Member     Chairperson

Public Relations Committee:                   Member     Chairperson

Special Events Committee:                      Member     Chairperson

Volunteer Coordination Committee:        Member      Chairperson

Musical, Dance or Artistic Talent:

Specific Type of Talent (Dance, Flute, Drums, Drawing): 

Other Areas Where I Would Like to Serve (Please Write In):

I’m Not Particular!  Call Me When You Need Me:

Tax-Deductible Monetary Donation ($25 covers one client for one treatment):

$5            $10            $15            $20            $25     

$50            $75            $100         Other (Please write amount)

 I will be sending a check  

                          or cash

In the amount of on (please type the date)  

                                                                To:

Shanti Wellness Project (SWP)

136 Grove Ave, Prescott, AZ  86301

Additional Comments or Questions: