Create Campaign Form Step 1 of 2 50% First name* Last name* Email address* Phone number*Mailing address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact* Email Phone Best time to call you?* Morning (8am-12pm) Afternoon (12pm - 5pm) Evening (5p - 9pm) How did you hear about the LifePump? How do you plan to fundraise (check as many as necessary): At work At church At school Through events Through friends and family Other If you choose "Other" Choose your gift!*AfricaHaitiNo t-shirt for me, but thank you!We would like to provide all campaign champions with a Design Outreach t-shirt to help start conversations and spread the word about their campaign. Please select which design you would like to receive. T-Shirt Size* Small Medium Large X-Large XX-Large Title of your campaign* This will appear as the title of your campaign page.Short bio about you and/or your organization*This short bio will appear in your campaign details.What compels you to start a campaign?*This will appear on your campaign page as your "appeal" to your friends and family.Campaign Goal* $10,000.00 $5,000.00 $2,500.00 $1,000.00 $500.00 Your website This will be used to include a link to your organization's or personal website on your campaign page.Twitter This will be used to include a link to your organization's or personal Twitter account on your campaign page.Facebook This will be used to include a link to your organization's or personal Facebook profile on your campaign page.Start Date* MM slash DD slash YYYY When would you like your campaign to start?Upload or Choose an Image* Upload Campaign Image Choose an Image Featured campaign imageAccepted file types: jpg, jpeg, png, gif.This will be placed on the top featured image of your campaign. Choose an Image Hidden Δ
