CHARGE Syndrome Foundation, Inc.
141 Middle Neck Rd.
Sands Point, NY 11050
I am enclosing my gift of: Amount $ ____________ (US funds)
Please make checks payable to CHARGE Syndrome Foundation, Inc.
Payment Info:
Check
Card number: ____________________________________
Expiration Date: _____ / _____ Security Code: _____
In Honor of: _____________________________________
In Memory of: ____________________________________
Donor's name: ____________________________________
Home Address: ____________________________________
City / State / Zip Code: _____________________________
Day Phone: _______________________________________
Email Address: _____________________________________
Signature: _________________________________________
Please Print and Return to the CHARGE Syndrome Foundation