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Playground Donation

Playground Donation

 

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Playground Donation Form 

Your Contact Information:
(* Denotes required field)
Title: *
First Name: *
Last Name: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Phone:
Email Address: *
Reenter Email Address For Confirmation: *
Receipt Preference: You may send a receipt for my donation to my email address.
Please send a receipt for my donation by mail to the above street address.

Your Donation Information:
Donation Amount: *  to be charged to the following credit card:
Cardholder's First Name: *
Cardholder's Last Name: *
Card Number: *       Mastercard Logo Visa Logo Amex Logo
CVV Security Code: *   What's This?
Expiration Date: * Month: Year:
 
Notes/Special Instructions:

Clicking the "Submit" button will immediately charge the amount above to the specified credit card.
The charge will appear on your credit card bill as "CHABAD HOUSE CENTER OF KC".

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