Donation Form

Consider making a meaningful gift to support programs that provide lung health and clean air education throughout Southern California.

Make a Meaningful Gift

Amount

$1,500 Provides 50 Adults with Lung Health Screenings

$1,000 Provides 30 Families with Life-Saving Asthma Management Tools & Resources

$500 Provides 50 Students After School Environmental Education

Type of Donation

One Time DonationRecurring Donation

Contact Information

First Name

Last Name

Company Name

Address

City

State/Province

Zip/Postal Code

Home Phone

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Payment Information

Payment Options

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

State/Province

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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.