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LAFP Foundation Donation Form
The Foundation is a 501(c)3 tax-exempt corporation and is the only charitable organization in Louisiana that exists to improve and increase access to health care by investing in the specialty of family medicine.
Contact Information
AAFP ID#:
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Member Type:
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Active
Life
Resident
Student
First Name:
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Last Name:
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Address:
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City:
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State:
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Zip Code:
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Home Phone Number:
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Cell Phone Number:
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Office Phone Number:
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Email Address:
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Donation Information:
Donation Amount: (choose one)
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$25
$50
$100
$250
$500
$1,000
Other
If you marked other, how much would you like to donate?
Is this a recurring donation? (choose one)
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One-time Donation
Monthly Donation
If you marked monthly donation, how long would you like to make this monthly donation?
I would like this donation applied to the following:
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General Fund
LSU - New Orleans Gerald R. Gehringer Family Medicine Award
LSU - Shreveport Michael O. Fleming Family Medicine Award
Tulane Family Medicine Excellence Award
Resident Award of Excellence
Payment Information:
Credit Card Type
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Mastercard
Visa
American Express
Discover
Cardholder's Name
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Credit Card Number
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Expiration Date
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Security Code
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Billing Address:
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City:
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State:
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Zip Code:
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