Donation Form

* Required Fields

Donation Information
Amount
Type of Donation	One Time Donation Recurring Donation
Frequency
	You may select your gift preference from this drop-down list. If not selected, your gift will be used Where Needed Most.
Purpose of Gift
	Tribute Optional: Select from the drop-down list of occasions and name the honoree in the space below. Provide a complete mailing address if you would like us to send a card to the honoree (or family of).
Occasion
Honoree Name
Add'l Note
Recipient First Name
Recipient Last Name
Recipient Address
Address Line 2
City
State/Province
Zip/Postal Code
Recipient Email

Contact Information
* Donor First Name
* Donor Last Name
* Address
* City
* State/Province
* Zip/Postal Code
* Home or Mobile Phone
Business Phone
* Email

Payment Information
Payment Options

Credit Card Information
Card Holder Name

Card Account Number
Expiration Date
* Security Code Click here for CVV2 information 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 keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.

Contact Us: HealthEd Connect •• 1401 West Truman Road, Independence, MO 64050 •• 816.833.0524 Ext 4115 •• [email protected]