HELEN'S WALK

SPONSOR A WALKER

updates: last modified 05/14/2008
Title: (required)  

Your First Name: (required)
Your Last Name: (required)
Name of Walker you're sponsoring: (required)
Your Mailing Address: (required)
Your City: (required)
Your State: (required)
Your Zip Code: (required)
Your Telephone with Area Code (required):   
Other Telephone with Area Code:  
Your E-mail:
Please add me to your mailing list: (required)
 Yes No

Donation Information

 Please fill in all that apply:
I am sponsoring in the amount of: (required) $
Comments:
Do you prefer to make this donation anonymously? (required) Yes No
Do you work for a Matching Gift Company? (required) Yes No
If yes, please provide the name of the company

Credit Card Billing Information
Credit Card Type: (required)  
Credit Card Number: (required)  
Expiration Date: (required)  
3 or 4 digit Credit Card Security Code: (required)

For Visa, Mastercard and Discover, the credit card security code is the last 3 to 4 digits of the number located above your signature on the card. For American Express credit cards, this 4-digit code is located on the front of the card, above the credit card number.

 

Name on card: (required)
Credit Card Billing Address: (required)
City: (required)
State/Province: (required)
Zip/Postal Code: (required)
Telephone with Area Code: (required)    
Credit Card Comments:

For more information contact:

Development Department

141 Middle Neck Road
Sands Point, NY 11050

516-944-8900 Ext. 254 (Voice)

516-944-8637 (TTY)

516-767-1738 (FAX)

E-mail: development@hknc.org

 

updated: 05/14/2008

Copyright © 2007 Helen Keller National Center. All rights reserved.