Become A Friend Of The Free Clinic - Friends of The Free Clinic Pledge Form – Become a sustaining friend of the Free Clinic of Simi Valley

Join the Friends of the Free Clinic

Donor Information

* Indicates required field

Name *

First

Last

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number (Home) *

Phone Number (Business) *

Fax Number *

Pledge Information

Friends of the Free Clinic who pledge to contribute a minimum of $1,000 or more annually, receive the following benefits:

The donation will be made in the form of: *

Check Credit Card PayPal

Will the gift be matched by a company/family/foundation? *

Yes No

Organization: *

I wish my gift to be anonymous: *

Yes No

Use the following name(s) on acknowledgements: *

Payment Instructions

1. Complete and submit this online form above.

2. Donation Options:

Please Click the button above that says "Submit Donor Information" before proceeding to Credit Card Donation --->

Payments can be made via any credit card or by PayPal. Payments are processed through PayPal, but you are not required to have a PayPal account.

Friends of the Free Clinic Pledge Form
File Size:	316 kb
File Type:	pdf