Pledge Application

Full Name: *

Your Gender: *

Male

Female

Your E-Mail Address: *

Street Address: *

City / State: *

Zip / Postal Code: *

Country: *

Phone: *

(Include your country and area code.)

Type of Sponsorship: *

I want to be a Child Sponsor ($50 per month)

I want to be sole sponsor of a child ($200 per month)

I want to be a Safe Passage Partner (Minimum $10 per month)

I want to be a Classroom Partner ($100 US per month or more)

I want to be a Mother Sponsor ($50 per month)

I want to be sole sponsor of a mother ($200 per month)

I would like to pay: * $

every: *

Month

3 Months

Year

Payment Options: *

I will pay by check. (For US Sponsors only.)

I would like to pay with a credit card. (Please contact me for this information.)

I will pay by automatic withdrawal. (Please send me further information. For US Sponsors only.)

I will pay by online donation.

I will pay to my country's account. (For International Sponsors only.)

Please send me information for Safe Passage's account in::

I have heard about the project from::

Please write any questions, special notes or comments below::

Safe Passage | Camino Seguro