___ I would like to serve on the Advisory Board
___ I would like to be a member of the Support Team
___ I am willing to do two free eulogies a year
___ I am willing to donate the use of my church or facility for services
___ I would like to assist/donate for the cost of funeral arrangements
___ My funeral home is willing to work out funeral payment plans for families that are in need
___ I would like to volunteer my services in assisting families in crisis by doing the following:________________________________________________________________________
___ I have talked to the following individuals/churches/funeral homes and they have indicated they would help. You can contact them at:

Name/Church/Funeral Home __________________________________________
Address _____________________________________________
Phone _____________________________

Name/Church/Funeral Home __________________________________________
Address _____________________________________________
Phone _____________________________

Your Contact Information
Name _____________________________________________________________
Address _____________________________________________
Phone _____________________________  Email _________________________

Please mail or Fax to:
Harkins Community Memorial Foundation
c/o Rockford Park District Foundation
401 South Main Street
Rockford, Illinois 81101
Fax: 815-987-1671