Global Donation Form – NicaClinic – The Roberto Clemente

105 West Monument Street
Baltimore, Maryland
21201

1 kilometro antes de Limon 1
Carratera Tola-Salinas,
Rivas

Nicaragua: 011-505-8887-7413

$ Donation Amount:

Dedicate this Donation

Yes, please
No, thank you

Dedication Type

In honor of
In memory of

Honoree Details

First Name *

Last Name

Would you like us to notify anyone of your donation?

Yes, send an eCard
No thanks

Notification Details

First Name *

Last Name *

Email Address *

Personal Info

First Name *

Last Name

Email Address *

Donation Total: $50.00

Yes, please
No, thank you

First Name *

Last Name *

Email Address *

Personal Info

First Name *

Last Name

Email Address *

Donation Total: $250.00

Yes, please
No, thank you

First Name *

Last Name *

Email Address *

Personal Info

First Name *

Last Name

Email Address *

Donation Total: $50.00

Global Donation Form – NicaClinic

Honoree Details

Notification Details

About Us

Links

Contact Us

Our US Office

Email us [email protected]

Nicaragua

Call us 011-505-8887-7413

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Honoree Details

Notification Details

Honoree Details

Notification Details