We are working to make your online donation
quick and easy! You will soon be able to use
your credit card & have your donation processed
immediately. Until then, please use this form to support CHADD's
mission of helping individuals and families affected by AD/HD!
Donation Form
Please print this form to mail in with your donation.
Make your check payable to CHADD and mail to:
CHADD
8181 Professional Place - Suite 150
Landover, MD 20785
Name________________________________________________________________
Email
Address________________________________________________________
Organization_________________________________________________________
Address_____________________________________________________________
City________________________________
State__________________________
Zipcode_________________
Country___________________________________
Phone__________________________________________
Amount of
Donation__________________________________________________
Type of Donation (Please check next to
appropriate type of donation)
________General
Donation
________ In Honor of (Please
see below)
________ In
Memory of (Please see below)
________Matt Cohen Scholarship
Fund
________Young Scientist Research
Fund
________Other (Please
describe_________________________________________)
Credit Card
Information
Name as it Appears on
Card________________________________________________
Card
number__________________________________________________________
Type (Accepted: Visa, Mastercard, AMEX,
Discover)__________________________
Expiration
Date_______________________________________________________
Amount authorized for
donation________________________________________
Memorial/In Honor Of Donations (Please print and mail with contribution)
I am making a contribution of:
____$500
____$100
____$50
____$25
____Other (amount $______________)
Please tell us about YOU-the person making this
gift:
Title________
First
Name________________________________________________
Last
Name________________________________________________
Suffix____________________________________________________
Address Line
1___________________________________________
Address line
2____________________________________________
City_____________________ State___________
Zip_____________
Country___________________________
Email Address (if
applicable)_________________________________
Daytime
Phone_____________________________________________
Company_________________________________________________
Please tell us who this gift will honor/memorialize:
Name_________________________________________
Your relationship to the
honored/memorialized__________________________________________
Please send notification of this gift to:
Title________
First
Name________________________________________________
Last
Name________________________________________________
Suffix____________________________________________________
Credit Card
Information
Name as it Appears on
Card________________________________________________
Card
number__________________________________________________________
Type (Accepted: Visa, Mastercard, AMEX,
Discover)__________________________
Expiration
Date_______________________________________________________
Amount authorized for
donation________________________________________
Address Line
1___________________________________________
Address line
2____________________________________________
City_____________________ State___________
Zip_____________
Country___________________________
Email Address (if
applicable)_________________________________
Daytime
Phone_____________________________________________
Company_________________________________________________
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