Academy for Five Element Acupuncture

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Community Clinic Fund Drive

Thank you for choosing to support Academy for Five Element Acupuncture. The aim of our drive is to fund new chairs for our low-cost community clinic.

Our goal is to purchase 10 new Zero-Gravity chairs. The total cost is $927.00. Your contribution will help us to reach our goal, no matter the amount.

We appreciate your generosity and look forward to your involvement with Academy for Five Element Acupuncture.

"Generosity is the virtue that produces peace".

Community Clinic Fund Drive:

Contribution Amount:

First Name: *

Middle Initial:

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

I would like my gift to remain anonymous

If you choose to give anonymously, your name will not be listed as a donor on social media posts, the website, or the newsletter. You will still receive an emailed receipt.

Your Payment Information:

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *