Alder Health Services Donation Form

Thank you for supporting Alder Health Services. 100% of your contribution makes a difference in the lives of individuals, families and communities in South Central Pennsylvania. Please consider supporting our programs and services at one of the annual donation/giving levels designated below or make a contribution at the level with which you are most comfortable.
Donation Levels 
  Level Range
    Cure Sponsor 
$5,000 and up
    Treatment Sponsor 
$2,500 - $4,999
    Prevention Sponsor 
$1,000 - $2,499
    Care Sponsor 
$500 - $999
    Support Sponsor 
$250 - $499
    Education Sponsor 
$100 - $249
    Awareness Sponsor 
$15 - $99
* required information
Donation
Select Gift Frequency and Amount
I would like to make a one-time gift for the following amount:
:* $
I would like to make a recurring gift.
Gift Amount* # of Payments Payment Frequency Total Gift Amount
$ X = $
NOTE: Each payment, including the first payment, will be made on day 15 of the month based on the payment frequency you have indicated.
Donor Designations
Select a designation for your contribution
General Support %
Patient Assistance %
Family Medicine %
Mental Health Services %
HIV/AIDS Services %
Donor Information
First Name:*
Middle Initial:
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Payment Information
:*
:*
:*   Explain
Credit Card Type:*
                  
Credit Card Expiration:*
Billing Information
If the billing information is the same as the contact information check this box.
If not please fill out the information below:
:*
:
:*
State:
:
:*
Country:*
Type the characters you see in the picture below:*
By clicking Submit,
your credit card will be processed