Patient Campaigns

Yes! I will make a contribution to help COTA.

Please Make Your Checks Payable to COTA.

I would like my donation to honor ________________.
(Enter patient name, and include in memo line on check.)

Name ____________________________________________________________________

Address __________________________________________________________________

City______________________ St__________ Zip _________________

Email _____________________________________________________

Thank you so much for your contribution!
Mail this form and your check to:

COTA
2501 West COTA Drive
Bloomington, IN 47403

Also indicate on envelope the name of the participant to be credited.

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