Registration Details

I am donating on behalf of:

First Name

Last Name

Company/Organization (If applicable)

Phone

Mailing Address

City

State

Postal Code

How would you like your name/your organization name listed in promotional materials?

Gala Selections

Donation Options

Scholarship Fund Donation I would like to give a donation to help fund therapy for underserved individuals!

any dollar amount

Purchase Details

I would like to pay with my credit cardPlease contact me with more information about my selectionsPlease invoice me for my purchase

TOTAL AMOUNT

AIS is a 501(c)(3) Non-Profit Organization Tax ID #13-39717403

Payment Information

Name on Card

Card Number

Code

Billing Email