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Christian Healthcare Ministries Payment Form
Personal Information
First Name
*
Last Name
*
Email Address
*
Please update your information only if you have had a recent change.
Street Address
City
State
Zip/Postal Code
Phone Number
Please refer to your statement for gift amount.
Please select the appropriate item:
*
Single ($150.00)
Couple ($300.00)
Family ($450.00)
Please select the appropriate item:
*
Brother's Keeper - Single ($12.00)
Brother's Keeper - Couple ($24.00)
Brother's Keeper - Family ($36.00)
*
3.50% Payment Processing Fee
Thank you for your contribution!
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