Reach More, Care More Pledge Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
My/our ongoing annual support to Georgia Wellness:* This field is required.
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
6
Georgia Wellness will receive my investment as:* This field is required.
A one time payment
Equal payments over 3 years
Varying payments over 3 years
Other
7
Please indicate the anticipated date of your initial gift.* This field is required.
Date
Month
Day
Year
8
If you are making payments over 3 years, please indicate the amount of your initial gift.
9
I would like my gift to remain anonymous.* This field is required.
YESNO
10
Please select your desired Naming Opportunity.* This field is required.
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
11
Please indicate how you would like your name displayed.
12
Signature
Clear
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