Payment Information
Yes! I would like to be the miracel for those in our community!
Amount
*
Please charge this card monthly for 12 months.
Contact Information
First
*
Last
*
Name to be Displayed
Address
*
City
*
State
*
Zip
*
Phone
*
Email
*
Message or Dedication
Anonymous (donor info. will remain on the receipt but not listed on the site.)
Credit Card Information
Type
Card Type
Visa
MC
Amex
Discover
*
Number
*
Expiration
Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
*
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
*
Code
*
Use contact info above.
Name
*
Address
*
Zip
*
Note
I'd like to go one step further and cover the 3% processing fees.
Total Amount
Submit