From The Heart Donation Form

Please select the type of donation and the amount you would like to donate.*
- I would like to make a gift for the following amount:
- I would like to make a monthly recurring gift for one year.
Here's my gift amount:*
if other:*
Recurring Amount:*
if other:*
I would like to apply my donation to:*
Credit Card Information
Please enter the credit card information below.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Name as it appears on card:
Donor's Billing / Mailing Address
Please enter your billing / mailing name and address below. Your billing information must EXACTLY match the address printed on your billing statements.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address*
Company: (if applicable)
Mailing Information Matches Billing Information?*
- Yes
- No
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I would like to receive a presentation certificate for my gift of $150 or more*
- Yes
- No
Presentation Certificate Information
The Wheelchair Foundation Wishes To Thank:*
For The Gift Made In The:*
First & Last Name*
Presentation Folder Mailing Address Same As Billing Address?
- Yes
- No
Presentation Folder Mailing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How did you hear about Wheelchair Foundation?
Please select from below
School Name
Other
If "Other" was selected, please describe.

Credit Card Information

Donor's Billing / Mailing Address

Presentation Certificate Information

How did you hear about Wheelchair Foundation?

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