Donation Form

The Stroke Recovery Center provides all it's services to patients for free. We rely heavily on donations and memberships to maintain our services and facilities. Use the online form below or download the form and mail it to the Stroke Recovery Center.

For check payment, make checks payable to Stroke Recovery Center. Please download the form, fill it out, mail it with your check to the Stroke Recovery Center.

For credit card payment, fill out a form and call Diane Hanner at 760-323-7676 or e-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Donations

Membership/Donations:

Membership

Donation Gift Amount $

This gift is:

Donation Note

Membership/Donation Amount $

Please send acknowledgment to:

Name*

Address*

City*

State*

Zip*

Phone*

E-mail*

Card to be signed as

Donor/Purchaser Information:

Donor Name*

Donor Address*

Donor City*

Donor State

Donor Zip*

Donor Email