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Reach More, Care More Pledge Form
Please fill out and submit this form for your pledge.
12
Questions
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1
Name
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First Name
Last Name
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2
Email
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example@example.com
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3
Phone Number
*
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Please enter a valid phone number.
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4
My/our ongoing annual support to Obria:
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5
Reach More, Care More Expanded Support:
*
This field is required.
Please select your Total 3 Year Commitment.
$1,000,000 : Founder
$750,000 : Champion
$500,000 : Builder
$250,000 : Provider
$100,000 : Protector
$50,000 : Ambassador
$25,000 : Partner
$15,000 : Impactor
$10,000 : Friend
$5,000 : Supporter
$1,000 : Contributor
Other
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6
Obria will receive my investment as:
*
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A one time payment
Equal payments over 3 years
Varying payments over 3 years
Other
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7
Please indicate the anticipated date of your initial gift.
*
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-
Date
Month
Day
Year
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8
If you are making payments over 3 years, please indicate the amount of your initial gift.
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9
I would like my gift to remain anonymous.
*
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YES
NO
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10
Please select your desired Naming Opportunity.
*
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Please Select
Exterior Entry Brass Plaques - $1,000,000+ (3 available)
Entry Plaque to Obria Suite - $750,000+
Entry Plaque to Pediatric Suite - $750,000+
Elevator - $500,000+
Thrive Classroom - $250,000+
Waiting Room (2 Available) - $50,000+
Obria US Room (1 Available) - $25,000+
Obria Exam Room (10 Available)) - $25,000+
Receptionist Area - $10,000+
Pregnancy Consultation Rooms (4 Available) - $10,000+
Pediatric Exam Rooms (5 Available) - $10,000+
Volunteer Room - $10,000+
Nurses Office - $5,000+
Empowered Office - $5,000+
Exchange Office - $5,000+
Fatherhood Office - $5,000+
Outdoor Planters (2 Available) - $5,000+
Childcare Area - $5,000+
In Honor/Memory wall plaques (15 Available) - $1,000+
None
Please Select
Please Select
Exterior Entry Brass Plaques - $1,000,000+ (3 available)
Entry Plaque to Obria Suite - $750,000+
Entry Plaque to Pediatric Suite - $750,000+
Elevator - $500,000+
Thrive Classroom - $250,000+
Waiting Room (2 Available) - $50,000+
Obria US Room (1 Available) - $25,000+
Obria Exam Room (10 Available)) - $25,000+
Receptionist Area - $10,000+
Pregnancy Consultation Rooms (4 Available) - $10,000+
Pediatric Exam Rooms (5 Available) - $10,000+
Volunteer Room - $10,000+
Nurses Office - $5,000+
Empowered Office - $5,000+
Exchange Office - $5,000+
Fatherhood Office - $5,000+
Outdoor Planters (2 Available) - $5,000+
Childcare Area - $5,000+
In Honor/Memory wall plaques (15 Available) - $1,000+
None
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11
Please indicate how you would like your name displayed.
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12
Signature
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