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Shalom Community Park Imagine Together Campaign Pledge Form
Please verify reCaptcha before submitting the form.
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First Name
*
Last Name
*
Phone Number
Email
*
How would you like to be contacted?
Phone
Email
*
Are there additional family members making this donation with you?
Please Select One
No
Yes
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First Name
*
Last Name
*
Phone Number
Email
*
Do you want add another family member?
Please Select One
No
Yes
*
First Name
*
Last Name
*
Phone Number
Email
*
Do you want add another family member?
Please Select One
No
Yes
*
First Name
*
Last Name
*
Phone Number
Email
*
Do you want add another family member?
Please Select One
No
Yes
*
First Name
*
Last Name
*
Phone Number
Email
*
Home Address
Unit/Apt
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zipcode
*
I/We hereby pledge to contribute cash and/or assets to the Imagine Together Community Park Campaign in the amount of
*
I/We wish to make payment in the form of:
Cash
Check
Credit Card
Stock
IRA Distribution
*
What would you like your payment schedule to be?
Please Select One
I am prepared to fulfill this pledge in full today.
I will fulfill this pledge in installments.
Total number of installments:
0
1
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36
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Please select your installment billing schedule:
Monthly
Quarterly
Semi-Annually
Annually
*
First installment date:
*
Final installment date:
Maximum three years
*
Would you like to be publicly listed for this campaign in order to encourage others to support this campaign?
Please Select One
Yes
No
*
How would you like your name(s) to be publicly listed?
Sun, May 19 2024
11 Iyyar 5784
Sun, May 19 2024 11 Iyyar 5784