Donate a wheelchair and send a card to honor a loved one.
Use the form below to send a card "In Honor" or "In Memory" any time of year (pictured right).
Card Styles
Click images to see details
* required information
Donation Amount
Enter any amount $71.88 or above.
:* $

Donor Information
First Name:*
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:
ZIP/Postal Code:*
Province:
Country:*
Phone:*
Birth Date:(mm/dd/yyyy)
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What prompted you to donate?:*
Event / church / friend / Ambassador or other's name:

Payment Information
You may make your payment with a credit/debit card or Paypal.
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:
:*
:
:*
State:
:
:*
Country:*

Enter information about the card recipient

Message for inside card:*
Select a Card Style:* In Honor Card
In Memory Card
Recipient Name and Address:*
By clicking Submit,
your credit card will be processed

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Refund Policy
In the case of unauthorized credit card transactions,
refunds are available upon request within 30 days of the original transaction date.

"In Honor" Card

"In your honor
a wheelchair has been gifted."

"In Memory" Card

"In honor of your loved one,
a wheelchair has been gifted."

Change a Life for $77.91