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American Dysautonomia Institute (ADI)

                                                                                 Donate Via Credit Card on PayPal


To make your tax deductible donation, via PayPal, please click on the link above and then:


Click on "Make a Donation."
Leave "Item" blank.
Insert an amount in "Unit Price."
Click on "Update Totals."
Follow the instructions from PayPal.                                  

If you need a further receipt for tax purposes, or would like a letter sent in honor, memory, or commemoration, please notify us via e-mail, providing (in the e-mail) the information requested in the form below.  Our e-mail address is:  staff@adiwebsite.org. 

Donation Form (For Traditional Mail)-American Dysautonomia Institute
                                                        Suite 2
                                              2135 Oakbrook Blvd.
                                          Commerce Twp., MI 48390
                                              Phone: 248-470-3992


            E-mail: staff@adiwebsite.org       www.adiwebsite.org

                                            Reaching For A Cure   


Your contribution is tax-deductible pursuant to Sec. 170 of the Internal Revenue Code
 

                                     Please Print All Information

Date:_______________

Enclosed is my gift of $____________________________________made payable to


the American Dysautonomia Institute.





Your name_______________________________________________________________





Address_________________________________________________________________





City___________________________________State__________Zip Code____________



E-mail and/or phone_______________________________________________________


How do you wish the card to be signed?


_________________________________________________________________________


Please send notification letter to:





Name____________________________________________________________________





Address__________________________________________________________________





City____________________________________State__________ Zip Code___________


Your gift may be made as a memorial, honor, or commemorating donation. 


Please complete the following:


In honor of:_______________________________________________________________





In memory of:_____________________________________________________________





Commemorating:___________________________________________________________





 ________________________________________________________________________(Please indicate birthday, wedding, anniversary, bar/bat mitzvah, communion or other event)





Special instructions (if any):_________________________________________________





________________________________________________________________________


With your generous help we can speed the day when dysautonomia can be promptly diagnosed, effectively treated, and then cured.


                                                     


   Please Complete and then Print this Form.  Mail It,  with Your Check Made       


                  Payable to the American Dysautonomia Institute, to:                       

                              American  Dysautonomia Institute 


                                       2135 Oakbrook Blvd.


                                  Commerce Twp., MI 48390


                                                                                    
                      




                    Please Print This Page and Mail with Your Donation