Donation Form

Travel Payment

Payment Information

Where and when are you traveling?

Payment Amount

$300 Deposit

$600 Deposit (2 People)

Type of Payment

One TimeRecurring

Your Contact Information

First Name

Last Name

Company Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Help Us Cover Transaction Fees

Help cover the 2.89% transaction fees so that more of your payment goes directly to LPGM.

Yes! I want $0.00 to go to LPGM, bringing my total payment to $0.00.No. I will simply pay $0.00.

Payment Information

I would like to pay with my:

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.