Name:

Mailing address

City      State      Zip 

Daytime Phone Number 

Home Phone Number

Email address 

I would like to sponsor   1    2   3   4 student(s) at the

Select a School
Christian Center for Educational Development (CCED) in San Juan de la Maguana, Dominican Republic
Jim Smith School in El Rosario, Dominican Republic
Lucille Rupp School in San Juan de la Maguana, Dominican Republic
Lamb of God School in Elias Piña, Dominican Republic
Christian Center for Integral Education (CCEI) in El Cercado, Dominican Republic
Villa Esfuerzo (Eastern Evangelical School) in Santo Domingo, Dominican Republic
Villa Hermosa (My Eternal Refuge School) in La Romana, Dominican Republic
Wherever it is most needed, please select for me.

Select a child
I have selected a child from the photo page. I would like to sponsor student(s) number
(For Villa Hermosa only, if you know the child's full name, please type that in the box and we will see if we can locate that child.)
I would like you to select a child for me

Payment Choices
By Check
By Credit Card
Auto Withdrawal Program from your checking account

Frequency (Please skip this if you are paying by credit card).
Monthly - $26.00 USD
Quarterly - $78.00 USD
Semi-Annually - $156.00 USD
Annually - $312.00 USD

Invoicing (Please skip this if you are paying by credit card).
If you pay by check, we will send you an invoice before your payment is due.  I would like this invoice sent to:
My e-mail address
To my regular mailing address

Auto Withdrawal Authorization (Please skip this if you are paying by credit card).
If you would like to allow your payments to be taken out of your checking account, please fill out the following:
 My willingness to provide you my account numbers indicates that I am authorizing Solid Rock Missions to make auto withdrawals to cover my payment to the sponsorship program.
I agree.  Please call Solid Rock Missions at 419-956-4077 or 888-765-4376 to give use your bank routing and account information.

Signed (type your name) 

Date