Our Online Recurring Donation Form allows you to make contributions to The Foundation for Post-Acute and Long-Term Care Medicine, Wall of Caring, and the Foundation's Futures Program by allocating your donation amount across one of these areas over time with payments made automatically according to the schedule you set up.  All recurring online contributions are processed by our secure PayPal site.

Contribution Levels

Contribution Levels
Level Range
Supporter $25 - $99
Friend $100 - $249
Patron $250 - $999
Charter Club $1,000 - $4,999
Founder's Club $5,000 - $9,999

Internet Explorer Users:

We recommended that you submit our forms using a modern compliant browser such as an up-to-date version of Chrome, Firefox, or Safari and avoid using MS Internet Explorer, especially older versions, which present some compatibility problems.

Contributing the Foundation for Post-Acute and Long-Term Care Medicine - Online Recurring Donation Form

Contributor's Information

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The information on this page pertains to your personal information.

First Name(*)
Please provide your full name.

Middle Initial
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Last Name(*)
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Credentials
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Please list credentials separated by commas.

Address(*)
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City(*)
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State(*)
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Zip(*)
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Phone(*)
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Fax
Please type your full name.

E-mail(*)
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AMDA Member(*)
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Are you an AMDA member?

 

Donation Preferences

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The information on this page pertains to your donation preferences.

Listing Option(*)
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Select to include your name if you'd like your name to appear in our list of contributors. Select to exclude your name if you're making an anonymous donation.

Matching Option
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Indicate whether your employer has a matching gift program or not.

 

Donation Selection

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The information on this page pertains to your donation specifics.

Select Contribution Fund(*)
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Select a fund to contribute to.

Dedication Type
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Chose an option that describes the type of dedication you're making as it might apply to who or what, otherwise leave it set to 'None."

Dedication To
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Please enter to whom or to what your dedication is intended.

Dedication
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Please include a paragraph if you wish to add your sentiments to your dedication.

Amount of Each Recurring Payment(*)
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Select a recurring amount representing your first payment which you will be making now.

Recurring Frequency(*)
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Select the frequency you would like in making your recurring payment.

Total Number of Monthly Payments(*)
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Select the total number of recurring payments you wish to make.
*Indefinite payments will continue until you contact our office and instruct us otherwise.

Total Number of Yearly Payments(*)
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Select the total number of recurring payments you wish to make.
*Indefinite payments will continue until you contact our office and instruct us otherwise.

Total Donation
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Donation Summary
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Validation

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The information on this page pertains to the verification and security of your submission.

Captcha(*)
Captcha   RefreshInvalid Input

Type the four lower case characters shown in the box above on the left into the box on the right and click Submit. You may click the Refresh link above as many times as you need to until you're confident you see the letters clearly.