Donation Form

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* Mandatory fields

*First name

*Last name

*Birthdate

mm/dd/yyyy

Occupation/Place of Employment

*e-Mail

*Phone

*Address Line 1

Address Line 2

*City

*State

*Zip Code

Access Card Number

*How would you like your donation used?

General

Boat Purchase Fund

Para-Adaptive Rowing Program (PARP)

Choose one

If the gift is in memorial of or in honor of someone, please indicate who:

*Amount ($USD)

* Code

Type the 6 characters you see in the picture