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Donation Type:*

One-time Donation
Monthly Donation
Annual Donation

One-time Donation Amount

Monthly Donation Amount

Foothill Partner – $5/month
Timberline Partner – $10/month
Alpine Partner – $15/month
Summit Partner – $20/month
Other

Annual Donation Amount

Foothill Partner – $60/year
Timberline Partner – $120/year
Alpine Partner – $180/year
Summit Partner – $240/year
Other

Other One-time donation amount

Other Monthly donation amount

Other Annual donation amount

On Behalf Of

In Memory Of

All donations made ‘In Memory of’ are allocated to the Brain Injury Alliance of Colorado Operating Endowment Fund. This permanent fund will be invested so that earnings can be used to support our annual operations or for other specified projects, as the need arises for our clients. This endowment is being established in order to build a solid financial bedrock for the organization, ensuring that we will always be able to respond to the emerging needs of the brain injury community.

Donor Information

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Employer (Optional)

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Additional Information

What prompted your decision to donate today?

Yes, please share my comments (May be shared online or in print using your first name.)

What is your connection to brain injury?*

How did you hear about BIAC?*

How did you hear about BIAC (Other)

Payment

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Date I would like my donation to start coming out of my account:

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I would like my donation to come out of my account on:

1st of each month
15th of each month

I agree with the terms and conditions below*

Yes

I hereby give permission to the Brain Injury Alliance of Colorado to take my donation from my bank account on the 1st of the next month. If my donation is recurring monthly, I understand that my donation will continue to come out of my bank account on the first of each month unless I contact the Brain Injury Alliance of Colorado to have it stopped.If my donation is recurring annually, I understand that my donation will come out of my bank account on the 1 year anniversary of the initial donation unless I contact the Brain Injury Alliance of Colorado to have it stopped.

I agree with the terms and conditions below*

Yes

I authorize the withdrawal of a donation from the account indicated. I understand that by choosing Bank Account, my contribution will be processed.

Credit Card*

CC Fee Offset*

Yes! I would like to help offset the credit card fees of $3
No thanks

Total

$ 0.00

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