Donation Information
Amount
$1,000
$500
$250
$100
$50
$50 Monthly Giving
$25 Monthly Giving
Type of Donation
One Time Donation
Recurring Donation
Frequency
Monthly
Complete the following fields if this gift is a tribute.
(optional)
Type of Tribute
In Memory Of
In Honor Of
Tribute Name
Send Notification to:
Title
First Name
Last Name
Address
Address 2
City
State/Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Alaska
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip/Postal Code
Email
Contact Information
First Name
Last Name
Company Name
Address
Address 2
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland & Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
Phone
Email
Your entry is not a valid email address!
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 Lebanon Family Health Services and I will donate $0.00.
No. I will donate $0.00 and Lebanon Family Health Services will cover the processing costs.
Credit Card Information
Card Holder Name
Visa
MasterCard
Discover
Card Account Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
24
25
26
27
28
29
30
31
32
33
34
Security Code
Billing Address
Same As Above
Address
City
State/Province
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland & Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
Email
Your entry is not a valid email address!
Next
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
: Lebanon Family Health Services
615 Cumberland Street
,
Lebanon
,
PA
17042
.
Phone:
(717) 273-6741
WIC:
(717) 273-6940
Fax:
(717) 273-6337
Web:
lebanonfamilyhealth.org
©2024 SofterWare, Inc. v.2024.01-B