Project ElderCool Donation Form

$ Donation Amount:

Provide an air conditioner to a person in need - $250 donation
Provide two air conditioners to people in need - $500 donation
Provide three air conditioners to people in need - $750 donation
Provide four air conditioners to people in need - $1000 donation
Add funds to a person's electric account to help run their air conditioner - $100 donation
Other

Dedicate this Donation

Dedication Type

First Name *

Last Name

First Name *

Last Name *

Country *

Address Line 1 *

Address Line 2

City *

State *

Zip/Postal Code *

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

State *

Zip / Postal Code *

Donation Total: $250.00

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