Printable Donation Form



GIFT INFORMATION

I CHOOSE TO DONATE: □ $6 □ $60 □ $260 □ $600 □ $6,000 □ Other $ ____________

Name_____________________________________ (OPTIONAL) Business Name_________________________

Address___________________________________ City____________________ State______ Zip Code______

Email Address______________________________

DONATION METHOD

□ My check is enclosed (Please make payable to American Academy of Child & Adolescent Psychiatry)

□ A one-time donation. Please charge my: □ □ □

Credit Card number: ________________________________ CSC Code_________ Expiration Date________

Name on Card: _____________________________________ Signature________________________________

□ A monthly donation. Please deduct $___________ from my credit card.

HONOR OR MEMORIAL GIFT INFORMATION (OPTIONAL)

This gift is: □ in honor of □ in memory of___________________________________________________

Please send notification to:

Name___________________________________ Address___________________________________________

City____________________________________ State__________________________ Zip Code___________

Your Personal Message________________________________________________________________________

OTHER INFORMATION

□ Please send me more information about a bequest gift to AACAP.

□ Yes, I would like to volunteer for Advocacy Day on Capitol Hill, May 9-10, 2013

MAIL TO

AACAP

P.O. Box 96106

Washington, DC 20090-6106

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MAIL-IN DONATION FORM

YES!

I want to support the 60th Anniversary Challenge!

60 Years. 60%. $60.

(All 60% challenge donations support Campaign for Americas Kids)

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