2013 Giving Tuesday

* indicates required field
DONOR INFORMATION
Name: *
     
Address:  
   
City:  
State:
Zip:  
Phone:  
Email Address:   
DONATION INFORMATION

Charity:
Enter the Recipient Code from the list into the Donation fields below along with a Donation Amount.  The Total Donation field must match the total amount of the individual donations entered.
 
Recipient Code     Donation Amount
Donation 1:  :      $
Donation 2:  :      $
Total Donation: * $ 
PAYMENT INFORMATION
Your credit card information will be requested after you complete this form.

A required bank fee of up to 3% and administrative fee of 2% will be deducted from your donation.
TRIBUTE
My donation is a tribute to someone special:
The following fields are only required if your donation is a tribute.
Honoring: *  
Please Notify:   
Address:   
   
City:   
State: 
Zip:   
ACKNOWLEDGE GIFT
Acknowledge Gift:
By checking the above box, your name and contact information will be sent along with the donation to the charity you have selected.
No goods or services have been received in return for this donation.

For questions regarding this online donation form please call Community Health Charities of CA at 800-569-0442