#site_config.memo_site_title#

DONATION FORM

Phone: (661) 635-3050

If you would like to consider making a contribution now, please fill in the fields below, then press "Submit My Donation."
Thank you for your interest in Clinica Sierra Vista

This gift is from:

661-555-5555

Donation Types

  1. In Memory of - donation in memory of someone no longer with us
  2. Women, Infants and Children (WIC)
  3. Behavioral Health Services
  4. HIV/AIDS
  5. Clinical Support Programs
  6. Homeless/Healthcare Mobile Health Services
  7. Adolescent Family Services
  8. Health Insurance Assistance Program (HIAP)
  9. General Donation - This donation will go where needed
$10 $25 $50 $100 Other

Please notify the following person that this gift has been made to Clinica Sierra Vista

661-555-5555
Captcha: (please answer the following question to submit your request)
What is the sum of 8 + Ten ?

Please check that all parts of the form above have been completed and then press "Submit My Donation" only once. The confirmation page will appear shortly afterwards. Then you will be able to proceed through paypal paying via Credit Card or Paypal account (not required for payment) to complete the process.

This is a Secure Form , hosted on an SSL Server.
Any information you enter is encrypted.

For technical questions and comments regarding this website,
please contact the Webmaster.

Clinica Sierra Vista is an equal opportunity employer and complies fully with the Americans With Disabilities Act. CSV supports the "Community Health Center Veterans Hiring Challenge" and encourages military veterans to apply.

Donate