Annual Drive/Donation/Pledge Form

Select a giving level:

WESTERN - $25,000 and above.LIBERTAS - $15,000 and $24,999.STUDIUM - $10,000 to $14,999LONESTAR - $5,000 to $9,999OAK BRANCH - $2,500 to $4,999OLIVE BRANCH - $1,000 to $2,499FLEUR-DE-LIS - $500 to $999GREEN JAY - $1 to $499

Donors will be listed in our Annual Report within these ranges

Gift Type

One Time/Recurring GiftPledge Gift

Please accept my DONATION in the amount of

Please accept my PLEDGE in the amount of

Please enter your PLEDGE date

MonthDayYear

My employer will match my gift to Western Academy

Company Name

Add a note or instruction concerning your Pledge or Donation

Giving Method

Online donation via credit cardCheck by mail

Internal

Your Donation/Pledge Amount to WA

My Products

One Time Gift (Annual Drive)

USD for each year

Monthly Recurring Gift (Annual Drive)

USD for each month

Bi-Annual Recurring Gift (Annual Drive)

USD for each six months

Yearly Recurring Gift (Annual Drive)

USD for each year

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

Number of Payments

Your Name*

FirstLast

WA Affiliation

Your Primary Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Email Address*

You may notice a slight delay in the checkout process as we process your payment with our payment processor (Stripe).

NOTE: You may need to enable popups on your laptop or desktop for the payment screen to appear.

If you have any questions regarding your pledge, payment or subscription, you may reach out to Mr. Tim Keenley at Tim.Keenley@westernacademy.net or via phone at 713-461-7000

Western Academy is a 501(c)(3) non-profit organization, therefore, your donation is deductible for income tax purposes as allowed by law.