Michael’s Kids
Child Sponsorship Sign-up
(Please print this form, fill it out, and return to LifeChange Uganda)
Personal Information
First Name: ____________________Last Name: __________________________
Street Address: _____________________________________________________
City:
Country (if other than US): ____________________________________________
Phone: ___________________________Alternate Phone____________________
Email:_____________________________________________________________
Best way to contact me: _______________________________________________
Sponsorship
Information
__I would like to sponsor one child at $15 a month
__I would like to sponsor two children for a total of $30 a month
__I would like to sponsor
several children a month for $15 each.
Number
of children ___________Total amount per month $________
Choosing a Child (select one of the following options):
__I would like LifeChange to choose a child for me.
Gender preference: ٱ Male ٱ Female ٱ I have no preference
__I have chosen a child from the website that I am interested in sponsoring.
Child’s
Name_________________________________________________
Child’s
Reference # ____________________________________________
Payment Information (select one of the following options):
__I would like to send a check each month to LifeChange.
__I would like to call in my credit card number for payment each month.
__I would like LifeChange to keep my credit card information on file and
automatically process my sponsorship payment each month.
Credit Card
Information (if last payment option was
chosen):
Name as it appears on card:________________________________________
Type of Card: __Mastercard __Visa
Expiration Date (mm/yyyy) ________/__________
Security Code (on back of card): _______________
If last payment option
was selected please read and sign:
I,
____________________, hereby acknowledge that I have provided
LifeChange International with credit card information
to automatically
process sponsorship payments on a monthly basis
until my 2 year sponsorship
pledge is completed or I personally contact LifeChange and request that the
processing of my card information be
discontinued. I understand that my
card
information will be used only by LifeChange
for processing my sponsorship
payments and that my information will not be
released to any third party.
Signature__________________________________Date_______________
LifeChange Sponsor Agreement:
Please initial, sign,
and date that you have read and understand the following:
I, ___, understand
that I am committing to a 2 year sponsorship pledge.
I, ___, promise to
contact LifeChange if for some reason I cannot make
a pledged monthly payment.
I,___,
have read and understand LifeChange’s privacy
policy..
Signature____________________________________Date______________
LifeChange
Ph: 303-797-0201
Fax: 720-344-4521