Pledge Form | DPT Alumni Scholarship

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Thank you for your interest in the University of Mary Hardin-Baylor Doctor of Physical Therapy Alumni Scholarship! You can pledge over a period of time by filling out this form (we recommend monthly giving over five years). Once the form is completed, we will process your pledge and update the website to reflect your entire pledge amount. Once again, thank you for your support of the program!

First and Last Name *

Email Address *

If pledging $5,000 ($84 per month for five years) or more, what name(s) do you want on the donor wall/art installation in Hardy Hall?

For example: Brad and Shannon Bankhead

Monthly pledge amount:

$21 ($250 per year)

$42 ($500 per year)

$84 ($1,000 per year - minimum for Donor Wall)

$167 ($2,000 per year)

Other:

For how many years?

1 Year

2 Years

3 Years

4 Years

5 Years (recommended)

Other:

Via...

Credit/Debit Card

Check (We will send you a pledge reminder with return envelope in the mail)

Clear selection

Credit card number (if applicable)

Credit card expiration date (if applicable)

YYYY

Credit card CVV (if applicable)

Preferred start date to begin pledge:

YYYY

Phone number or other comments:

Comments or questions:

Submit

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