Individual Assumption of Risk Form

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Child Sponsorship Amount*
Price:
A 3% fee is charged to Breathe Partners each time a credit card is charged on this site. Would you please consider covering this fee?*
- Yes
- No
Or, if you desire, you may mail a check to Breathe Partners, 51 Reason Lane, Coatesville, PA 19320 for no additional fee and include a note designating the support.
3% Processing Fee
Price: $0.00
Total
$0.00
Child ID #*
Name
First Last
Email
I want to receive periodic updates from Breathe Partners via email*
- No
- Yes
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

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