Piryx™

Share This Page
Tweet 1

Contribute to HealthPAC

Join our cause and contribute today to support access to affordable, quality health care!

Contribution Amount

$25
$50
$100
$250

$500
$1,000
$2,500
$5,000

Personal Information

First NameRequired
Last NameRequired
EmailRequired
Home AddressRequired
Home Address (line 2)
CityRequired
StateRequired
Zip/PostalRequired
Phone NumberRequired

Employment Information

EmployerRequired
OccupationRequired

Payment Information

Debit/Credit Card

Card Number
CSC ?
Expiration

Routing Number
Account Number

Billing Information

Same as home address.
Billing Address
Billing Address (line 2)
City
State
Zip/Postal

Contribution Type

Make this monthly recurring contribution

for

I want to publish my name to the Contribute to HealthPAC giving stream! (Note: your contribution amount will not be shown)

Your donation will appear on your credit card or bank statement as "RALLY/PIRYX"

Amount:

Your donation is being submitted. Please be patient.

By clicking submit you agree to our refund policy in our terms of service.

Contributions or gifts to HealthPAC are not deductible as charitable contributions for federal income tax purposes. State law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer for individuals whose contribution exceeds $100 in a calendar year.

Paid for and authorized by HealthPAC

This form is secured using 256-bit SSL encryption.

Piryx - The Social Giving Platform

Now fundraising is as easy as writing a blog or posting a status update and can be integrated into your website, product or mobile app. With Piryx, causes raise money online in more volume and much more effectively across the web. To learn more and create your own free account visit Piryx.com.