Whitetulip Health Foundation Pledged Donation Form

Your Pledge, Your Impact

The examples below illustrate how different contribution levels support our scholarship programs.
You may pledge any amount that aligns with your means and intention, including a custom amount of your choice.

$18,000 – Suggested pledge amount for a attending physician couple

$12,000 – Suggested pledge amount for an attending physician

$6,000 – Suggested pledge amount for a resident/fellow couple

$3,000 – Suggested pledge amount for a resident /fellow and nonphysician medical professionals

Any other amount that you can pledge will also be greatly appreaciated.

Donor Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please describe your current job title or role*

Which state and city do you live in?*

Pledged Amount (Please enter the total amount you plan to pay in 2026, not monthly payment)*

Name under which donor will donate (name of spouse, company, or alias) *

Donation Method*

Donation Schedule: In how many installments do you plan to meet the total pledged amount?*

For each installment, you will be making the following payment:

Specify the months for your installment payments

Jan.Feb.MarchApril

MayJuneJulyAug.

Sept.Oct.Nov.Dec.

Additional details: (Any details you would like to let us know, for example under what name should Whitetulip produce the donation receipts?)