Donation Form

Thank you for your interest in Fitness and Movement Basics!

9:30 - 10:15 a.m., Mondays, July 6 - August 31

$10 for series

Class Registration

Amount

Contact Information

First Name

Last Name

Company Name

Address

City

State/Province

Zip/Postal Code

Phone Number

Emergency Contact

Help Us Cover Credit Card Processing Costs

Simply leave "Yes!" checked below to help VNA Community Healthcare by covering the online credit card processing fee. Thank you!

Yes! I want 100% of $0.00 to go to VNA Community Healthcare and I will pay $0.00.No. I will only pay $0.00 and VNA Community Healthcare will cover the 2.79% credit card processing costs.

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.