Mail-in Donation
(Printable Form)

 

 I want to help find a cure for Cerebral Palsy

  I have enclosed a donation in the amount of $_____________.

 

Please check one of the following:
___ Enclosed is my check. ___ Please charge my credit card.


Name: _________________________________________________

Address: _______________________________________________

City: ______________________ State: _____ Zip: ____________

Country: _______________________________________________

Telephone: _____________________________________________

Email address: __________________________________________

 

Type of card: ___VISA ___ Mastercard ____AMEX ___Discover

Card Number: __________________________________________

Expiration Date: ________________________________________

Name on card: __________________________________________

Signature: __________________________________________

 

Thank you for your generous support.
Please mail to this form to:


Inspire the World Foundation
1015 Longview Avenue
Pismo Beach, CA 93449


Tel (805) 773-0951
Fax (805) 773-0931