Donations - Memorial Healthcare

Donor Information

Donor Name

First Last

Email

Address

Street Address City State ZIP Code

Phone

Gift Amount

Frequency of Donation

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.

I wish this gift to be used for:

Other

Payment Information

Credit Card Type

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Donation Information

This donation is being made:

Name

First Last

Please Notify

Notification of gifts is sent immediately, the amount is kept confidential.

Address

Street Address City State ZIP Code

Donation Options

I wish to remain anonymous.
Please send me information on planned giving.
Please send me information on leaving a gift in my will.
Please send me information on giving a gift of stock.

All contributions are tax deductible. Thank you for your gift.

Would you like to receive the Foundation newsletter?

Yes
No