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Payment System


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*First Name:
Middle Initial: *Last Name:
I am making a Donation:
$25.00
$50.00
$100.00
$ Other
 
In Honor of...
In Memory of...
I am making an Annual Appeal contribution:
$25
$50
$100
$150
$250
$500
$ Other
I am making a Membership payment:
$45.00 / Family Child Care Provider/Individual
$50.00 / Group Family Child Care Provider
$60.00 for 1-5 Staff Members Child Care Center/School Age Care Program
$Enter Additional staff member amount here. ($12.00 for each additional staff member, not to exceed $400.00)
*Organization:
Enter N/A if not applicable
*Address:
*City:
*State: *ZIP code:
*Work Phone Number:
*Home Phone Number:
Fax Number:
*Email Address:
*Confirm Email Address:
Comments: