Monthly Donation Form- Ogembo Orphanage

Name:

Address

City/State/Zip

Home Phone

Cell Phone

Email

Check box to receive updates about 2nd Chance and its African Partners by email

I would like my donation applied toward:

Child’s name

Child’s name

Child’s name

Child’s name

DONATION INFORMATIONMonthly Gift Amount _____ $25.00 per child x ________ children = __________________ Process my donation on the 1st 15th of each monthThis donation is made by an individual a business

I prefer to give by Credit Card (please fill out the credit card section below)

Pre-authorized debit (please fill out pre-authorized debit section below)

Credit CardCard type Visa MasterCard

Process my donation on the 1st 15th of each month cvc: ______Card # : ________________________________ expiry: (mm/yy) ________________

Monthly Donation Form- Ogembo Orphanage

Name on card: _______________________________________________________________Signature: _______________________________ Date: _______________________

Pre-Authorized Debit (PAD)Please attach a VOID cheque.

Process my donation on the 1st 15th of each month Signature: _______________________________ Date: _______________________I may revoke my authorization at any time, subject to providing notice of 15 days. To obtain a sample cancellation form, or for more information on my right to cancel a PAD agreement, I may contact my financial institution.