Donate Now First Name: Last Name: Address: City: State: Email: Name as you wish to appear in donor recognition publications: Choose a set amount from below or write in your own: Custom Donation $682 for an entire year of well & acute healthcare for a child ages 1 – 18 $1,016 for an entire year of well-child care for an infant (age 0-12 months) $1,839 for an entire year of healthcare for a child with special needs $500 leases a computer for one exam room to manage the electronic medical records of patients $310 pays for APC medical supplies for one day $200 for one month’s prescription medications & an inhaler for a child with severe asthma $145 pays for one acute care visit for a sick child $75 pays for 10 age-appropriate books for 10 APC patients to take home after their medical appointment If choosing ‘Custom Donation,’ how much do you want to donate? $ This gift is made: In Memory Of (optional) In Honor Of (optional) Name on Gift (optional): Please send an acknowledgement of this tribute gift to: Name: Address: