Villa Teresa Donation Form

Donation Frequency*

One-TimeMonthlyQuarterlyAnnual

Calculation

Donation Amount*

I would like 100% of my donation applied to {staffName}*

Yes, I want to cover processing feesNo, I would not like to cover processing fees

Are you giving this gift in memory of a loved one? If so, please share their name.

Total Donation Amount*

USD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Name

First NameLast Name

Email*

example@example.com

Phone*

Area CodePhone Number

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Same as mailing address?*

YesNo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Click the submit button above to complete your {donationFrequency} donation of ${calculation} to support {staffName}. I authorize Villa Teresa to use my bank/credit card account for future payments. I understand I may cancel this authorization at any time.

Staff Name