The Barry Wint Memorial Fund

Established February 23, 2008 at the

Advancements in Medicine 2008 Conference

Registration Page Two

 
Pledge and Contribution Form
 

First Name (*Required)

Last Name (*Required)

Middle Initial

Address (*Required)


Address (line 2) / Post Office


Country
 

City/Parish (*Required)
State (*Required - if US)

Zip Code (*Required)

E-Mail Address (*Required)
Telephone Number (*Required) ( ) -  
 Medical Mission to Jamaica:
Are you interested in Short-term Medical Missions opportunities in Jamaica?
Are you a member of the Diaspora?  (*Required)
  Fund Contribution:
US Dollars Jamaican Dollars
25.00   1000.00
50.00   2500.00
100.00   5000.00
500.00   10000.00
1000.00   25000.00
Other   Other
 
If other, enter amount here:  
(no dollar signs or commas, numbers only)
 

Donation schedule:
Monthly   Quarterly   Annualy   One Time
Thank you!
 
 
 
OSDJ, Copyright 2008 - 2009 All Rights Reserved.