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Donation Form
Amount
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$
1,000
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500
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250
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100
$
50
$
25
$
Recurring Pledge
One Time
Monthly
Quarterly
Annually
Fund
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General
Layne Staley Fund
Royale Lexing Memorial Fund
Anonymous Gifting
I would like this gift to remain anonymous
Would you like to Dedicate this gift in Honor or Memory of Someone?
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Yes
No
Who would you like to dedicate the donation to?
Does Your Employer provide Gift Matches?
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Yes
No
Who is your Organization/Employer?
Contact Information
Name
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First Name
Last Name
Email
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Address
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Would You Like to Receive Information about Planned Giving?
Yes