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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, chinitzpc@aol.com.  Website:  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:___________________________________________________________

Other:

 ________________________________________________________________________(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 

                                                                                Suite 2
                                                                   2135 Oakbrook Blvd.
                                                             Commerce Twp., MI 48390


                                                                                    
                      




                                              Please Print This Page and Mail with Your Donation

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