DONATION FORM | Cloud Mountain Retreat Center

Submission Date

What program would you like to designate your donation to?*

For which retreat are you offering your staff dana?*

Staff Dana Retreat Name

For PDF: copies the LABEL from Drop Down of Retreats for Staff Dana

Do you wish to make your staff offering anonymously?*

Yes
No

Do you wish to offer a special dedication to accompany your staff dana offering?*

Yes
No

Special Dedication*

Please write out your dedication in the following box below exactly as you would like to have it read in its entirety

For which retreat are you offering your meal dana?

Meal Dana Retreat Name

For PDF: copies the LABEL from Drop Down of Retreats for Staff Dana

Which meals would you like to offer dana for?*

Breakfast - $100
Lunch / brunch - $125
Dinner - $75
Full Day of Meals - $300

Are you flexible as to the date on which your meal dana is offered?*

Yes
No

What specific date are you requesting?*

Do you wish to make your meal offering anonymously?*

Yes
No

Do you wish to offer a special dedication to accompany your meal dana offering?*

Yes
No

If you choose not to offer a special dedication, please be aware our standard anonymous meal dedication reads: "This meal is offered anonymously by someone present on this retreat" (or, as applicable "not present on this retreat"). Our standard non-anonymous meal dedication reads: "This meal is offered by Jane/John S. of YourTown, WA."

Special Dedication*

Please write out your dedication in the following box below exactly as you would like to have it read in its entirety

What amount would you like to give to CM today?

Donation amount:

Your Donation Amount:

Would you like to make this a recurring monthly donation?*

Yes
No

Clicking "Yes" authorizes Cloud Mountain to charge your card in the amount specified on a regular basis.

For how many months?

Other comments:

GENERAL INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Alternate Phone

Email*

Payment Method

Select Payment Method*

Pay online
Pay by mail

Total

$0.00

Upon form submission, a summary will be sent to your email address. Please print out the form and send along with your check or money order to: Cloud Mountain Retreat Center, 373 Agren Road, WA 98611. Checks should be made payable to Friends of Cloud Mountain (or FOCM).

CREDIT CARD INFORMATION

Authorization

I authorize Cloud Mountain to process the payment of the amount above.

Credit Card

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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