Please enable JavaScript in your browser to complete this form.Honor your friends & family with a meaningful gift. Making a donation to the Alpha Omega Foundation US supports improving research, education, and public support for oral health worldwide. Please select from the list below which program/fund you are supportingCharitable Causes *Holocaust Survivors Oral Health Program:The Alpha Omega-Henry Schein Cares Holocaust Survivors Oral Health Program’s mission is to provide comprehensive oral health care to Holocaust survivors living in poverty across North America.Tribute Fund:Your donation will be used to support the foundation to meet its goals of engaging, inspiring and supporting oral health worldwide.Other:This donation is being given to support the Alpha Omega Foundation US program of your choice.Please select recognition typeRecognitionSend recipient an eCard:Minimum dollar amount is $18.00Send recipient a Tribute certificate in the mail:Gold Certificate is $72.00 and Platinum Certificate is $180.00No recognition:This is a donation that does not require a recognitionDonation Amount *Tribute Amount *Gold – $72Platinum – $180Donation Amount *Your Contact InformationName *FirstLastLayoutEmail *Phone *Please indicate the purpose of your donation and/or a message to include if the donation is for a tribute. Please send recognition of gift toNameFirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFeesPlease consider adding $2 to your gift to cover the cost charged by the credit card processing company.Total$ 0.00Payment TypeCredit CardCheckCredit Card *CardName on CardTo send a check, please click on the Submit button to receive additional information.Submit
