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IMPACT Trip Donations Form

Instructions Please fill in all the fields, below. After you click "submit", you will be taken to our payment processing page where you can enter your credit card information. PLEASE NOTE: YOU *DO NOT* HAVE TO SIGN UP FOR PAYPAL TO PAY ONLINE. ON THE RIGHT SIDE OF THE SECOND SCREEN ARE TWO SECTIONS - PLEASE REFER TO THE SMALLER SECTION ON THE LOWER RIGHT WHICH SAYS, "PAY WITH DEBIT OR CREDIT CARD..."
Your Name * First Last
Your Phone Number *
Total Dollar amount of donation. *
Select a team-member or team members to whom you would like to donate. If you select one individual your entire donation will go to that individual. If you select multiple individuals, your donation will be split equally among them. *
Coby BrackenDavid BrownJulie CeselskyAngelo CiconeGwen CiconeMaria CiconeHannah LeubeckerBeryl Wickham