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
-----------------------
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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