Gift Information

Please note that fields with an asterisk (*) are required. 

Donation Amount*
$

The minimum contribution amount is $10.00

Your contribution will be publicly acknowledged as follows:

Leaving the above field blank means we will use your name for public acknowledgement purposes. If you wish your contribution to be Anonymous, please indicate this in the space provided above.

Contact Information

Country*
State / Province*
Address*
City*
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Email*
Confirm Email*
Phone*

Tribute Information (optional)

I wish my contribution to be (fill in any that apply) 

In honor of
In memory of

Please send an acknowledgement of this contribution in honor/memory of to:

Name
Address

Payment Options

If contributing by check, please make your check payable to HCAO-Action and

send to us at the following address:

 

1443 SE 122nd Ave

Portland, OR 97233

Credit/Debit Card Payment

Amount*
$
Name on Card*
Card Number*

Security Code

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