Donation Form

Donation Amount:

Donation Categories

Annual Fund

% of

Language to Literacy

% of

Early Childhood Program

% of

Autism Progam

% of

Speech Program

% of

Unrestricted - please use where best needed

% of

I would like my donation to recur.:

Yes

Amount you would like to recur:

Frequency of donation:

Number of recurrences:

Date of your final recurring donation:

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Please confirm recurring donation:

This is in honor of:

This is in memory of:

Employer or company matching gift:

Include me in your mailing list:

Yes

Include me in your email list:

Yes

Comments & Other Instructions:

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

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Postal Code:*

Country:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Work Phone:

Email:*

Credit Card Information

Card Types Accepted:

Credit Card Number:*

Card Security Code:*

Expiration Date:*

Electronic Signature:*

I agree to pay above total amount according to card issuer agreement.Once the transaction has completed successfully, a confirmation receipt will be sent to the email address entered.

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