Donation Form

Kelli Wall

Extension 1349

Gateway Rehab is a 501(c)(3) nonprofit organization, contributions to which are tax deductible to the fullest extent permitted by law. Official registration and financial information may be obtained by calling Gateway Rehab at 412-604-8900, or by calling the Pennsylvania Department of State toll free (within PA) at 1-800-732-0999. Registration does not imply endorsement.

Online Donation

Use this form to make an online donation. If this is for something specific, please note that in the comment box

Donor information

Prefix*

First Name*

Last Name*

Address*

City*

State*

Zip*

Phone*

Email*

Gift Information

Designation*

This gift is in

memory

honor of

Person's Name

Please notify the following individual of my gift:

Person's Name

Person's Address

City

State

Zip

I wish my gift to be anonymous

Donation Information

Donation type

Onetime Recurring

Frequency

Number occurrences

Amount

Payment method

Credit Card Payment

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card type*

Card Holder Name*

Verification code*

Donation Form

Online Donation

Donor information

Gift Information

Donation Information

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