I herby authorize Memorial Healthcare Foundation to charge or deduct the amount above (minimum $10 transaction) from my credit card or bank account indicated below. I understand that each transaction will appear on my regular credit card or bank statement. I further understand that it is my responsibility to notify Memorial Healthcare Foundation if there are any changes to my credit card or bank account that will affect my Automatic Contribution Program participation. This authority remains in effect until I notify Memorial Healthcare Foundation in writing to change the amount of, or suspend, the automatic contribution. Memorial Healthcare Foundation can terminate this agreement at any time.
