Easterseals Rehabilitation Center donation form

Help local children and adults with disabilities achieve their dreams!

Give TODAY and you'll make a life-changing difference.

Your gift will stay LOCAL, empowering friends, neighbors, classmates, colleagues, and thousands of other kids and adults to reach goals for independence. Help the Easterseals Rehabilitation Center provide essential services and programs to individuals from our Evansville/Tri-State area!

Giving a monthly donation is the best way to make an impact. You may cancel or change this monthly donation at any time.

Additional Amount:

Is this a Pledge Payment?

Yes

If so, which event should this be attributed to?

I would like to make this gift in honor or memory of someone special

Honor Gift Type:

Honoree Title:

Honoree Name:

Notification Recipient Information

Notification Recipient Title:

Notification Recipient Name:

Notification Recipient Street 1:

Notification Recipient Street 2:

Notification Recipient City:

Notification Recipient State/Province:

Notification Recipient ZIP/Postal Code:

Message to Notification Recipient

Message Body:

Message Closing:

Message Signature:

Yes, include the gift amount in the message.

Billing Information

First Name:

Last Name:

Street 1:

Street 2:

City:

State/Province:

ZIP/Postal Code:

Email Address:

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Mobile Phone Number

Payment Information

Payment Method:

Credit CardBank Account

Credit Card Information:

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Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?

Checking Account Information:

Bank Routing Number: What is this?

Bank Account Number:

Verify Bank Account Number:

Account Type:

Checking
Savings

By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment.

Check Information

I would like to cover the credit card fee so 100% of my gift goes to Easterseals.

Credit Card Verification Code

The Verification Code is imprinted on credit cards to help merchants verify transactions when the actual card is not present, such as Internet purchases or donations. The merchant uses this number as part of the authorization process with the card issuer.

Visa, Master Card, and Discover:

The verification code for Visa, Master Card, and Discover is a 3-digit number printed on the back of your card. It appears after the account number or last 4-digits of your account number, in the signature panel.

American Express:

The American Express verification code is a 4-digit number printed on the front of your card. It appears above and to the right of the embossed account number.

Easterseals Rehabilitation Center
3701 Bellemeade Ave, Evansville, IN 47714 | 812-479-1411
Tax ID: 35-0909982
Easterseals and its affiliate organizations are 501(c)(3) nonprofit organizations.

Easterseals Rehabilitation Center
3701 Bellemeade Ave
Evansville, IN 47714 | 812-479-1411
Tax ID: 35-0909982
Easterseals and its affiliate organizations
are 501(c)(3) nonprofit organizations.

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