Please complete and include this form with
your check or money order made out to:
The Payson Road Organization
3767 Overland Ave
Suite 103
Los Angeles, CA 90034
310-364-1660
Please provide the following contact information:
Name Title Organization Address 1 Address 2 City State Zip Code Country Work Phone FAX URL
Yes! Count me in. I (we) would like
to help
Payson Road's continued efforts to educate, support and advocate for
eating disorder issues. Please accept my gift of:
| $2,000 (Mentors) | $1,000 (Partners) |
| $500 (Entrepreneurs) | $250 (Artist's Circle) |
| $100 (Creative Circle) | $65 (Ambassadors) |
| $Other | $35 (Friends) |
Professional Referral Network:
| Individuals: | Treatment Centers: |
| $65 (Basic) | $125 (Basic) |
| $125 (Silver) | $275 (Silver) |
| $250 (Gold) | $550 (Gold) |
| $1000 (Platinum) | $2500 (Platinum) |
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Thank you very much for joining the fight by supporting Payson Road!
