Full Name (*)

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E-mail (*)

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I would like to sponsor (sponsorship child/children's name)

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Date I will begin sponsoring (*)

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My sponsorship contribution
... 1 child @ $25
... 2 children @ $50
... 3 children @ $75
... 4 children @ $100

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I would like to make a general contribution
... General Contribution
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If you would like to give by check, please mail in your first month's sponsorship contribution to: Open Door Haiti PO Box 950458 Lake Mary, FL 32795. Please write "sponsorship: child's name" in the memo line.

Address

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Address line 2

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City (*)

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State (*)

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Zip code (*)

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Phone Number (*)

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