Secure Payment Form
Donation Summary:
Donation Date:
12/21/24
Donation Amount:
Designation (optional):
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180 Venice
180 Btown
Camp
Crocs 'n Socks
Edrick Gil
Shelby Gil
Carlos Portillo
JJM
Parent Life
Recurring Donation:
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Yes
No
Frequency:
-- Select --
Monthly
Quarterly
Next Payment Date (YYYYMMDD):
Checking Account Information:
Account Holder Name:
Bank Routing Number:
Bank Account Number:
Billing Information:
Company Name:
First Name:
Last Name:
Address:
City:
State:
Zip:
Country:
Phone Number:
Email Address: