DONATION FORM

I want to help Parents Helping Parents of Florida, Inc. (PHPF)  continue providing support and vital resource information to parents and families of children with disabilities.  I am enclosing my generous contribution of:

$10   $20   $30   $50  Other Amt.

Name:         

Email:     

Address: 

City:          State:     Zip: 

Credit Card Information:

(Please do not put spaces or hyphens between the numbers)

Card Number:    Expiration date: 

NOTE:  THE NAME AND ADDRESS GIVEN MUST BE THE SAME AS THAT OF THE ACCOUNT HOLDER

I would like to receive a copy of 'The Fountain' Newsletter.  Please add my name to your mailing list:

Finally, so that we may better serve you, please consider providing us with the following OPTIONAL information:

I am a: 

Parent of child(ren) with a disability  

Family Member   

Medical/Therapeutic Professional   

Educator   

  Other 

To make a donation by check, please print a copy of this form and submit it with your check made payable to PHPF, Inc.  Mail to:

PHPF, Inc.

P.O. Box 830802

Ocala, FL 34473-0802