Please print this page, fill it out, and send along with your contribution to the address indicated:
 

Send To:

Spastic Paraplegia Foundation, Inc.
Research Fund
P.O. Box 1208
Fortson, GA 31808

Payment Method:

   Enclosed is my check
   Please charge my credit or debit card account using the information provided below.

I'm happy to make a tax-deductible contribution to SPF of:
 $__________    $500    $250    $100    $50    $25  

 MasterCard    VISA

Card Number:  __________________________________________ 
Exp. (mm/yy)  ______/______

If you would you like this gift to be a tribute, please answer the following:

SELECT ONE. To Mark a Special Occasion:
   Birthday
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   Other _____________		 This gift is...
   In Memory of
   In Honor of

Honoree's Name:
______________________________________________
To have notification card(s) sent, please complete the following.

I would like a notification card without the gift amount mailed to:
Name: ________________________________________________________
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I would like a second notification card without the gift amount mailed to:
Name: ________________________________________________________
Address: ________________________________________________________
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