Easterseals Event Donation Form

Be a part of empowering young artists with Autism! 🎨

A gift to the Art for Autism Gala will help the Chartwell Center continue to provide academic, therapeutic, and vocational supports to children and adults with Autism.

Giving a monthly donation is the best way to make an impact. You may cancel or change this monthly donation at any time.

Additional Amount:

Billing Information

First Name:

Last Name:

Street 1:

Street 2:

City:

State/Province:

ZIP/Postal Code:

Email Address:

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Mobile Phone Number

Payment Information

Payment Method:

Credit CardBank Account

Credit Card Information:

Credit Card Type:

Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?

Checking Account Information:

Bank Routing Number: What is this?

Bank Account Number:

Verify Bank Account Number:

Account Type:

Checking
Savings

By checking this option, I agree to use my bank account as a payment method and authorize this organization to debit my bank account to fulfill my donation commitment.

Check Information

I would like to cover the credit card fee so 100% of my gift goes to Easterseals Louisiana Chartwell Center.

Credit Card Verification Code

The Verification Code is imprinted on credit cards to help merchants verify transactions when the actual card is not present, such as Internet purchases or donations. The merchant uses this number as part of the authorization process with the card issuer.

Visa, Master Card, and Discover:

The verification code for Visa, Master Card, and Discover is a 3-digit number printed on the back of your card. It appears after the account number or last 4-digits of your account number, in the signature panel.

American Express:

The American Express verification code is a 4-digit number printed on the front of your card. It appears above and to the right of the embossed account number.

Easterseals Louisiana
935 Gravier Street, Suite 720, New Orleans, LA 70112 | 504-523-7325
Tax ID: 72-0694376
Easterseals and its affiliate organizations are 501(c)(3) nonprofit organizations.

Easterseals Louisiana
935 Gravier Street, Suite 720
New Orleans, LA 70112 | 504-523-7325
Tax ID: 72-0694376
Easterseals and its affiliate organizations
are 501(c)(3) nonprofit organizations.