Thank you for your pledge to our Capital Campaign. This form is a pledge intent only. Please fill out the form below, and our Capital Campaign director will be in touch with you to discuss your contribution.


Fields marked with an asterisk (*) are required.


In support of the Capital Campaign for the VNA Respite House, I / we pledge a contribution of $ payable between now and December 31, 2018.

I / We plan to make the following payments:

$ on or before December 31, 2016

$ on or before December 31, 2017

$ on or before December 31, 2018

I / We would appreciate reminders prior to these payment dates via:



I / We understand these payments may be made by cash, check or credit card, in securities, or through the establishment of an annuity or other irrevocable planned gifts.

Please make checks payable to:

VNA Respite House Capital Campaign
1110 Prim Rd
Colchester, VT 05446

Have Questions? Call us: (802) 860-4437

Respite House is a program of the VNA of Chittenden and Grand Isle Counties, VT.


I would like my name listed as:I prefer to make this donation anonymously.

I wish to make this donation:
In memory ofIn honor of

It is my / our intention that my / our estate will honor this pledge.