Pledge Your Support for Theresa Chapman

50% of your pledge will be donated to Brain Tumour Foundation of Canada
50% will be donated to BEL Rotary

Fill out the form below to pledge your support.

Participant/Team:	Theresa Chapman
First Name: *
Last Name: *
Address 1: *
Address 2:
City: *
Country:
Province/State:
Province/State:
Postal/Zip Code: Must match billing statement
Phone: *
Email: *
Payment Method: *	Credit Card
Card Type: *
Card Number: *
Card Security Code: *
Card Expires: *	/
Name on Card: *
Donation Amount: *	$25 $50 $100 $200 Other $ Please only type whole dollars in the amount field. Donations under $10.00 are not supported.
Anonymous:	(Checking this will hide your name except for taxation purposes)
Privacy Agreement:	I understand that my contact information may be shared with Brain Tumour Foundation of Canada for receipting purposes.