Connect Click&Pledge

Your In Honor Donation

Recurring Option

One time onlyMonthly

Billing and Contact Information

First Name: *

Middle Initial:

Last Name: *

Email: *

Country: *

Address: *

City: *

State: *

Province:

Zip/PostalCode: *

Phone:*

Just a little bit more...

Honorarium and Notification Information

In Honor of *

Send notification to

Mailing Address (street, city, state, zip)

Additional Comments

Donor Information

Acknowledgement Preference *

Send a donation summary in JanuaryEmail an acknowledgement when my donation is processed

Honor/Memorial Gifts

I want to dedicate my donation to someone:

In Honor Of In Memory Of Tribute To

In Memory Of:

Honoree Name:

Send Email acknowledgement to:

Send Postal Mail acknowledgement:

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip/Postal Code:

Country:

Dedication Message:

Payment Details

CreditCard

Routing Number: *

Account Number: *

Check Number: *

Account Type: *

Check Type: *

Name on Card: *

Credit Card Number: *

Card Verification(CVV): *

Expiration Date: *

Invoice Number:

Purchase Order Number:

Name: *
Reference Number:

Matching Gift

Find out if your employer offers a matching gift program.

You will be charged:

Secured and Powered by Click&Pledge

Advanced Redirect

The patron will be redirect to the following pages based on the authorized result.

Important Note:

The redirect pages have to be secure otherwise no redirect will occur.
If your server is offline for any reason the redirect will fail, resulting in error. If the patron experiences a page not found based on your server’s availability it may result to double charges

Use complete URL including https://

Success landing page * :

Declined landing page * :

The following URL parameters are included in the response and may be used on the landing page via custom programming:

Example Success URL:
https://yourpageurl.com/success-page?on=123456&result=success&response=authorized&t=totalamount&refid=referenceid&trk=tracker

on = OrderNumber
result = success
response = authorized
t = totalamount
refid = referenceid
trk = tracker

Example Decline URL:
https://yourpageurl.com/decline-page?on=123456&result=failure&response=dcl&t=totalamount

on = OrderNumber
result = failure
response = dcl
t = totalamount

Your donation to the "Medical" Fund: