Donation Form

Together we give. Together we heal. Together we stand.

Thank you for your support of our mission to empower students with special needs during this unprecedented time.

Donation

Amount

$500.00

$250.00

$50.00

Type of Donation

One Time DonationRecurring Donation

Donation Designation (Optional)

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 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 Second Start Learning Disabilities Programs and I will donate $0.00.No. I will donate $0.00 and Second Start Learning Disabilities Programs will cover the processing costs.

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

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 (unless otherwise specified).

Terms/Conditions
By submitting your payment, you are authorizing us to charge the account above for the amount specified in the Transaction Amount field.