Mass Casualty / Bleeding Control Kits

MailChimp Tag / Form Name
Memo
Notes to internal Federation professionals
Your Information
Name*

First NameLast Name
Email*

Confirmation EmailConfirm email address
Mobile Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Information
Name of Your Organization
Are you submitting on behalf of a place of worship?

YesNo
How many congregants?*
How many Mass Casualty / Bleeding Control Kits does your organization currently have on hand?*
Enter "None" if none
Is an early childhood center part of your organization?

YesNo
How many students are enrolled in your Early Childhood Center?*
How many Mass Casualty / Bleeding Control Kits does your Early Childhood Center currently have on hand?*
Enter "None" if none
Date of Birth

MonthDayYear
Additional Registrant Name*

First NameLast Name
Enter their email to ensure they receive notification, too!

Confirmation Emailexample@example.com
Tickets: $##

___ of tickets cost is not tax-deductible.
Ticket options*
Every new and increased gift made to the 2024 UJA Annual Campaign will be matched 1:1 through our Match of the Century.

I would like to make a gift to the 2024 UJA Annual Campaign.
Amount in USD
Payment Information
Total Ticket Cost:

${ticketAmount}
Ticket payment due today by credit card (fees apply)
Total Gift Amount:

${giftAmount516}
Payment Options for Gift*

Credit Card (fees apply)CheckPlease bill me (payment is due in full by December 31, 2024)I intend to make a recommendation from my Donor-Advised Fund
My billing information is the same as my mailing address.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card Type*

VISA/MCAmerican ExpressOther
Send your check in the amount of ${totalAmount528} payable to Jewish Federation of Greater MetroWest to:

Jewish Federation of Greater MetroWest NJ
Attn: TBD
901 Route 10, P.O. Box 929
Whippany, NJ 07981-0921
paymentData
Total Ticket Cost (hidden)
Gift Amount
Ticket Amount to charge
Gift Amount to charge
Subtotal Amount to charge
Gift Amount to send check
Total Amount to send check
Total Amount for bill
Appeal code
Cc fee
TOTAL = Subtotal Amount to charge + fee
Should be Empty:

Your Information

Organization Information

Tickets: $##

Payment Information