Name*
Email Address*

Street*
City*
State* Zip*

Check 1 or more of the checkboxes below.

Ally Organization: $100.00 (Any organization or group of three or more persons whose primary purpose is other than providing services to victims of sexual and/or domestic violence.)

Individual member: $20.00 (Any person who subscribes to the purpose of the Coalition and who pays annual dues.)

KCSDV Member Program Advocate or Survivor: $5.00
KCSDV Member Program name

I will mail a check payable to KCSDV. I will pay with a credit card.

If paying by credit card, please enter the last four digits of the credit card you will be using.

Card number

If paying by credit card, you will be directed to the Click & Pledge secure online payment system after submitting this form.