Donation Form

Advocacy
Your support allows us to continue advocating for our patients by supporting policies which promote safe and healthy communities.

* Required Fields

Donation Information
Amount in support of Advocacy
Type of Donation	One Time Donation Recurring Donation
Frequency
If you’re willing, please share why you’re making a donation to Virginia Garcia
	Complete the following fields if this gift is a tribute. (optional)
Type of Tribute
Tribute Name

Contact Information
* First Name
* Last Name
Company Name
* Address
* City
* State/Province
* Zip/Postal Code
Home Phone
Work Phone
* Email
Alternate Email
Are you under 36 years old?	YesNo

Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $0.00 to go to Virginia Garcia Memorial Foundation and I will donate $0.00. No. I will donate $0.00 and Virginia Garcia Memorial Foundation will cover the processing costs.

Credit Card Information
Card Holder Name

Card Account Number
Expiration Date
* Security Code The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card. For American Express, the Security Code (CID) can be found on the front of the card.

Billing Address
Same As Above
* Address
City
State/Province
* Zip/Postal Code
Email

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.