PLEASE PRINT THIS FORM
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YES! I WANT TO SUPPORT THE VITAL WORK
OF THE BARR-HARRIS CHILDREN'S GRIEF CENTER

____ $50
____ $75
____ Friend $100
____ Patron $250
____ Benefactor $500
____ Leadership Society $1,000
____ Other: $____________

Enclosed is my check payable to the Institute for Psychoanalysis
or please charge my:

____ Visa
____ Mastercard

Card # _____________________________________

Expiration Date: ______________________________

Signature: __________________________________

Profession: _________________________________

Day phone #:________________________________

E-mail address: ______________________________

Mail to:

Chicago Institute for Psychoanalysis
122 S. Michigan Ave, Suite 1300
Chicago, IL 60603

Tel.: (312- 922-7474
Fax: (312) 922-5656
Website: www.barrharris.org

For additional information, phone (312) 922-7474
or e-mail: [email protected]