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CCHASM COVID-19 Donation Form

Instructions:

Complete the form below to make your online donation. Below is an option to submit a one-time or recurring donation. Once you submit, you will receive an emailed receipt for your transaction. We appreciate your support!

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Organization/Employer

Telephone Phone Number

Verify Email

Donation Amount

$1,000

$500

$250

$100

$25

Donation Schedule

Add 3% to my total amount to help cover the payment processing fees