Flower  Verland's Donation Form

Complete and Print Here to mail or fax this form to donate directly to Verland or click SUBMIT to contact us via email.


Should you wish to support direct support professionals like those depicted in the movie, Riding the Bus with My Sister, click here

1.  

The Verland Foundation, Inc.
Contributor Code No. 221
212 Iris Road
Sewickley, PA 15143-2400
- OR -

2.  

The Verland Foundation, Inc.
ICF/ORC
Contributor Code No. 9180
1511 Hawthorne Street
Natrona Heights, PA  15065-1630

3.  

Verland Community Living
Arrangement Homes (VCLA)
Contributor Code No.
126-7208
212 Iris Road
Sewickley, PA 15143-2400

How did you hear of Verland?

E-mail Address

Salutation

Daytime Telephone Number



Required

First Name


Last Name

Required         Required

Home Address

 

 

Address (cont.)

Organization

City

 

 

State/Province

 

 

Zip/Postal Code

 

 

Type of Gift:

 

 

Amount of Gift:

 

 

THANK YOU FOR YOUR CONTRIBUTION. Please provide any additional information you feel will be helpful.

Select any of the following options that apply:

Bill Me

Credit Card Credit Card Company:

Number

Expiration Date

Signature:

Call us at 412-741-2578 to provide credit card information

To send via United States mail , via fax to (412) 741-2350 or for credit card authorization,
please print, sign and mail this form to Verland. Print Here


Click below to submit to Verland via email.