SECURE ONLINE DONATION
YOUR CONTACT INFORMATION
Donor Name
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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YOUR GIFT TYPE
Choose your gift type
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General Gift
In Honor Of
In Memory Of
Full name of the person you wish to honor or remember:
Donation designation
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Greatest Need
Chaplain Patient Care
Hospice
Oncology (Edwards Cancer Center)
Nursery/Pediatrics
Cardiology (Hufstetler Heart Center)
Please notify the following person of my gift.
Recipient Name
Recipient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Comments / Special Message to Recipient
Please accept my donation of
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Please increase my gift by 3% to help cover the processing fees, so that 100% of my gift goes toward the mission.
*
yes
no
Gift Total
Amount
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USD
Description
Credit Card Details
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