BASE Camp Children’s Cancer FoundationBASE-Camp-logo-200.png

Charitable Contribution

I (we) are making a charitable contribution in the amount of: $ _______________.

I (we) are making a charitable in-kind donation valued at: $ _______________.

Please select a form of payment / donation:

____ Cash ___ personal check (enclosed) ___ credit card ____ food basket ____ restaurant

___ hotel accommodations ___ entertainment ___ office supplies ____ other

For credit card payments only:

___Visa ___ MasterCard ___American Express ___Discover

Card number: _____________________________________ Expiration Date: _________

Please charge the amount listed above to my credit card.

Signature:____________________________________

Please fill out the following contact information:

Name(s) as you wish to be listed: ____________________________________

Address: ____________________________________

City, State, Zip Code ____________________________________

Telephone Number ____________________________________

Email address: ____________________________________

Please mail this form to:

BASE Camp Children’s Cancer Foundation 

650 North Wymore Rd., #103, Winter Park, FL 32789

(407-673-5060)

 ___ Thank you sent  Office Use Only