Contact Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

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Payment Options *

Mail a Check (Payable to CHC, and mailed to The Community Health Clinic | 730 E North St | PO Box 329 | Shipshewana, IN 46565)

Credit Card by Phone (Please call the CHC at 260-593-0108 ext 100 with Credit Card info)

Online Donation (After submitting the form, use our "Give Now" button to be taken to a secure online donation page.)