Please fill out the information requested below. This form may be filled out online and submitted to CHILD by clicking the PAY ONLINE button at the bottom. This will also take you to a secure PayPal form. You don’t have to have a PayPal account, although you can create one if you wish. PayPal honors Visa, Mastercard, Discover, or American Express.

If you prefer not to pay online, you can print this filled-out form by clicking the PRINT & MAIL button at the bottom. Then mail it along with a check to the address indicated there.

All information will be held strictly confidential and used only for CHILD’s administrative purposes.

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All dues and donations are tax-exempt.

(Please wait to be taken to the PayPal page and re-enter your total contribution there.)

to: Children’s Healthcare Is a Legal Duty, 136 Blue Heron Place, Lexington, KY 40511