Thank you for your Donation

Thank you for your Donation

Your contribution is what keeps our efforts alive in ensuring the New Zealand Tuberous Sclerosis Complex community are informed, connected and supported.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

City / TownState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Date*

DayMonthYear
Date

My Donation (Credit/Debit Card)

Donate$200NZD

Donate$150NZD

Donate$100NZD

Donate$50NZD

Donate$30NZD

Custom Amount$10NZD

Quantity
Item subtotal:$0.00NZD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

OR My Donation (Online banking) Please complete the amount you would like to donate and we will email you the bank account details.
What is your connection to TSC?

I am an individual with TSCI am a relative of an individual with TSCI am a medical practitionerOther
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