Individuals and Organizations

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Contact

Name of Business, Organization, Church or Individual *

Contact Person's Name: *

If you, your business, organization or church group is interested in contributing and/or partnering with us, or want to sponsor a fundraiser(walk on your own) for a Saturday in September (National Sickle Cell Awareness Month), or during another month, please complete the applicable form(below).

*IMPORTANT NOTE

Complete the form that applies to your intended method of payment.

Address *

Address *

Choose *

Option One: Platinum - over $1,000

Option Two: Gold - $ 500

Option Three: Silver -$ 250

Option Four: Bronze -$ 100

Option Five: Supporter - $100

CHECK PAYMENT FORM

Contact Person's Name: *

Daytime Phone *

ONLINE PAYMENT FORM

Thank you for contacting us! Checks should be mailed to PO Box 71473 North Charleston, SC 29415. Make checks payable to COBRA Agency or Sickle Cell Services. If additional information is needed, we will contact you within 3 days.

Partnership Invitations

Name of Business, Organization, Church or Individual *

Email: *

Check here to receive email updates

City, State, Zip *

City, State Zip *

Individuals and Organizations (Invitation)

Choose *

Option One: Platinum - over $1,000

Option Two: Gold - $ 500

Option Three: Silver -$ 250

Option Four: Bronze -$ 100

Option Five: Supporter - $100

Email: *

Check here to receive email updates

Daytime Phone *

Partnering for better healthcare outcomes