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Neurogel en Marche - USA

Donation Form

CONTACT INFORMATION:

First Name:

Last Name:

Address:                                                              Email:

                                                                              Telephone:

City:                                                                      Zip Code:


Your email and address will help us confirm your gift.


Please check one of the following:


___ I am enclosing a check (Dollars only), or money order to: "Neurogel en Marche - USA"


___ I made a PayPal payment online (see Donate button below):

          Amount:__________ Date:_________


Please keep in mind that no amount is too small: your donation will be a precious gift that can help bring a cure for paralysis and neurodegenerative diseases to the diverse population worldwide.


Mailing Address:

Neurogel en Marche - USA, Attention Steven Zander, 9420 Holland Avenue, Bethesda, MD 20814

Email: NeM-USA@neurogelenmarche-usa.org



"...To Hope...To Walk...To Live"