Be A Good Samaritan

*This and all sums collected pursuant to the Good Samaritan Program will be paid into a fund to be administered by the Family Center for the purpose set forth above.
This authorization obligates me to pay the additional sum per month until such
time as I deliver to CPWS a written request that this obligation cease. Upon request, CPWS will terminate my Good Samaritan Program participation as of the next regular billing cycle, and I will no longer be obligated to make said payments.

For more information about the Good Samaritan Program contact: The Family Center at 931-388-3840 or