I Am Well Darke County Gifted Membership Program

I Am Well Darke County Gifted Membership Program
Your Name*

First NameLast Name
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Email*
example@example.com
Gift Recipient Details

Please enter the information for the person who you would like to receive the membership.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

Please select the membership level below. Your card will be charged monthly or annually depending on your selection, and you can cancel by emailing us at info@iamwellfoundation.org. When you click submit, you will be taken to our payment gateway, where you can pay with PayPal or scroll down to pay with Credit/Debit Card. *

Basic Membership (Monthly)

$20.00 for each month

Basic Membership (Annual) One Time Payment

Includes 2 months FREE when you purchase the annual membership up front.

$200.00 one-time payment

Basic Membership (Annual) Auto-Renewal

Includes 2 months FREE when you purchase the annual membership up front. Automatically renews each year.

$200.00 for each year

Enter coupon

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I Am Well Darke County Gifted Membership Program

Gift Recipient Details