Donation Form

Name *

First Name Last Name

Address *

Phone Number *

Area Code Phone Number

E-mail *

If you have a child with a learning disability:

Child's Name(optional)

Child's Age (optional)

Type of Disability (optional)

I would like my donation to: *

Directed to the greatest need I wish my donation to be anonymous Designate my donation to:(please state in the space below)

Where I would like my donation designated to.

Amount of your Donation

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Date

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