C&S Patient Education Foundation Donation Form
Step 1:  Donation Information
___ $10            ___ $250               
___ $25            ___ $500              
___ $50            ___ $1000              
___ $100          _____  Other

Message (If in honor of someone,  please include their address so that we may notify them)
_____________________________________________________________________

Use of Funds  ___ General/Unrestricted        ___ Research

Step 2:  Donor Information
Name                                                                                                                   

Address                                                                                                               

City                                                                State                Zip                        

Region                                                 Country                                                   

Phone                                                   Email                                                           

Add To Newsletter Email List?  ___Yes    ___ No

Step 3:  Payment Information
Type:  MasterCard          Visa           Check/Money Order          

Name on card                                                                                 

Card Number                                                  Exp. Date               

Card Verification Number                    
3 or 4 digit number found on the back of most credit cards, near the signature bar, after the account number.

Please make checks payable to C&S Patient Education Foundation

Step 4:  Send To:   C&S Patient Education Foundation
                                ATTN:  Rick Labuda
                                320 Osprey Court
                                Wexford, PA 15090

C & S Patient Education Foundation is a tax exempt charitable organization governed by Section 501(c)(3) of the Internal Revenue Code. Contributions to the Foundation are deductible as charitable contributions on your federal income tax return, subject to various limitations under the federal tax laws. For more information on your individual tax situation, please consult a qualified tax attorney, CPA or other tax advisor.
The official registration and financial information of the C&S Patient Education Foundation may be obtained from the
Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.

Thank You For Your Support!