Donation
Form
To encourage and facilitate communication among families with a member who has 5p- syndrome and to spread awareness and education about the syndrome to these families and their service providers.
Yes, I want to help the 5p- Society continue to support its Mission Statement and its family outreach support and educational initiatives.
Mission Statement
Donor Information
First name:
Last name:
Street address:
City:
State/Province
Zip/Postal code:
Country
Phone:
E-mail address:
Donation Information
Enclosed is my donation of: (a donation of $25 will pay from my annual membership dues)
$10
$25
$50
$100
$500
$1000
Other
Acknowledgement Information
This donation is being made in honor of a Super Hero with Cri du Chat Syndrome; in memory of a loved one; or in support of the following event: (please indicate below)
This donation is being made in honor of:
This donation is being made to help support the following event:
This donation is being made to renew my annual membership
Yes
No
This donation is being made in response to the Annual Appeal or Giving Tuesday
Yes
No
Please send an acknowledgement to:
You may print and return this form with your check to:
5p- Society
PO Box 268
Lakewood, CA 90714
or fax this form to 562-920-5240
You can continue below and pay with your credit card through a secure and direct PayPal link.
Donation Amount
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