THANK YOU so much for helping a child win his battle for LIFE!  A picture refrigerator magnet of your child and his or her caregiver with some information about them will be mailed to you. 
Please mail a check for $25 to: HOPE ALIVE CLINIC, PO Box 964, Medford, NJ   08055
(or use PayPal on this website).  Please clearly designate “Mom Tot”. 
If you have any questions, please contact Jolene Wagner hopealivehaiti@yahoo.com


______________________________________________________
Name
______________________________________________________
Street Address
______________________________________________________
City
_______________________
State
_______________________
Zip Code
_______________________
Email Address
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Special Notes to Jolene Wagner