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: [email protected]

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