Capital Campaign Gift Pledge Form

Capital Campaign Gift Pledge Form

Emergency Services Facility Expansion and Renovation Project
Date form is completed*

MonthDayYear
Date
Donor Information
Donor name(s)*

First NameLast Name
Donor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Donor Phone Number*
Please enter a valid phone number.
Donor Email*
example@example.com
Preferred contact method*
Please let us know the best way to contact you
Additional Contact Information if Applicable
I/we, name* , intend to provide a gift to the Ivinson Memorial Hospital Foundation in support of the Capital Campaign for the Emergency Services Facility Expansion and Renovation Project.
Type of Gift*

One-time giftPledge paid over multiple years (up to 5 years)
Gift Amount*
in USD
Total Gift Amount*
Anticipated Amount of Each Pledge Payment*
Anticipated Schedule of Pledge Payments*
ie: $1,000 paid each calendar year for a total of $5,000 by 2027
Gift Designation**

Emergency Services Facility Expansion and Renovation / Capital CampaignOther
*Gift Designation

Should unforeseen future circumstances arise where a specified restriction was made for this gift, and the specific need no longer exists, IMHF will undergo every effort possible to connect with the original donor and describe the circumstance. IF the donor is unable to be contacted, the restriction may be removed following majority vote by the IMHF Board of Directors, and the remaining gift amount will be applied to the funding category most closely associated with the original gift intent(i.e., technology & innovation, education excellence, capital construction, area of greatest need, or the Ray of Hope endowment).
Plan for IMHF to acknowledge the gift
Please let us know how you would like to be recognized or if you would like to remain anonymous.
Anticipated date of gift (or first pledge payment)*
Donor Signature*

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

Capital Campaign Gift Pledge Form

Donor Information

*Gift Designation