Donation Form

Your support will bring help and hope to the more than 153,000 children, adults, and veterans with epilepsy and seizure disorders in Kentucky and southern Indiana.
* required information
Select Gift Frequency
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: This transaction will count as the first payment toward your total gift amount.
Donor Information
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:
ZIP/Postal Code:*
Gift Note:
Payment Information
Payment Method
:*   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:

Matching Gift Information
Will this donation be potentially matched?
If you know the following information regarding the matching gift, please complete.
Company Name:
Matching Gift Amount:$

Additional Information
Designate My Gift: Epilepsy Research Project Fund
In Honor of
In Memory of
Shannon O'Daniel Memorial Scholarship Fund
Peggy Sherrell Memorial Scholarship Fund
Veterans Program
Hope for Hadley Jo Service Dog Project
Kevin Dowd Memorial Scholarship Fund
Donation in Honor/Memory of::

Subscribe to our eNewsletter!
General Subscription
By clicking Submit,
your credit card will be processed