2018 Annual Appeal Donation Form

Contact Information

First Name (Required)

Last Name (Required)

Address (Line 1)

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Address (Line 2)

City

State

Zip Code

Phone

E-mail Address (Required)

Donation Amount

$25 to purchase a one month gym membership
$50 to purchase a pedal exerciser
$75 for a one hour session with a movement therapist
$100 for an hour long adaptive yoga session
$250 to support life-changing advocacy services
$1000 to purchase an off-road wheelchair
Other amount

Other amount

Additional Comments (honor or memory gift)

Would you like to join our monthly eNews mailing list?

Yes, please.
No, thank you.

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Neurodiversity in the Workplace Partner Organizations