On-Line Donation & Monthly Partner Sign Up Form

Please fill out the form below.

God bless you and thank you for your giving.

First Name (as displayed on credit card) (required)

Last Name (as displayed on credit card) (required)

Donation Amount (required)

Please indicate if this is a special donation or if you would like to sign up to be a monthly partner. (required)

Is this a special gift for the "Maternity Leave Fund"

Credit Card Number (required)

Expiry Date mm/yy (required)

Security Code (required)

Street Address (associated with this credit card) (required)

City (required)

Province or State (required)

Postal Code or Zip Code (required)

Your Email (required)

Your Phone (required)

Would you like to keep in touch? Please indicate below: (required)

Send us a message if you like:

Enter This Security Code Below: captcha