Sponsorship Application
 
First Name
Last Name
eMail*
Phone Number
Address
City
State
Zip code
Country
Name of Child (N/A if no preference)

Sex
Boy  Girl 
No preference 

Donation Amount
$30 Monthly   $180 Semi-annually 
$90 Quarterly  $360 Annually 
Other 

Credit Card
American Express   Mastercard  
Discover  Visa  

Credit Card #
Expiration Date
Security Code
Name as it Appears on Card

Other Type of Payment
Checking  Mail Payment 
Savings 

Name of Bank
Routing #
Account #

Receive Information by
Newsletter  Brochure 
DVD 

Comment Box
 P.O. Box 123
Berrien Springs, MI 49103
269-471-2629 Office
1-800-704-7611 Toll Free
269-815-5064 Fax

           

© 2016 Orphans International Helpline
A Registered 501(c)(3) Nonprofit Organization
and a Non-Governmental Organization in Haiti