Marvel Fund Donation Form

I wish to make the following a gift in honor of Mike and Pam Marvel to establish the Johnston Health Foundation's Marvel Cancer Survivorship Fund:*

A gift of $500 or more qualifies you for membership in the Johnston Health Society and includes two tickets to our annual Toast to Our Champions donor appreciation event on Tuesday, April 29. At this special gathering, we will announce the creation of the Marvel Cancer Survivorship Fund.

Calculation

This gift is made by a(n)*

IndividualOrganization

Donor Name:*

As you wish to be acknowledged on a donor list.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

E-mail*

example@example.com

Phone Number*

Payment method*

Credit CardCheck

Make checks payable to Johnston Health Foundation and mail to:
P.O. Box 1376
Smithfield, NC 27577

Please write Marvel Survivorship Fund in the memo line.

Donation amount*

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Optional - Include a special message for Mike and Pam.