The Feingold® Association of the United States
 11849 Suncatcher Drive, Fishers IN 46037

Fill out the following form, print, and mail to the address above.

Donation Form
I want to donate $ for
        Outreach to Parents, Teachers, Doctors
        Research Funds
        Financial Aid to those who cannot afford the Program materials
        Maintenance and Improvement of the International Materials
        Wherever it is needed most

COMMENT:
Your Name:
Your E-mail Address:
Your Phone#:
Your Mailing Address:
Method of payment
Check Enclosed Visa Mastercard
Credit Card No.:
Expiration Date
CVV number (last 3 numbers on back of credit/debit card)
Card Holder Name & Address
(if not same as above)