Memorial Healthcare Foundation Online Donation
Donor Name: *
Email: *
Address:
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Gift Amount:

*

Frequency of Donation:


I herby authorize Memorial Healthcare Foundation to charge or deduct the amount above (minimum $10 transaction) from my credit card or bank account indicated below. I understand that each transaction will appear on my regular credit card or bank statement. I further understand that it is my responsibility to notify Memorial Healthcare Foundation if there are any changes to my credit card or bank account that will affect my Automatic Contribution Program participation. This authority remains in effect until I notify Memorial Healthcare Foundation in writing to change the amount of, or suspend, the automatic contribution. Memorial Healthcare Foundation can terminate this agreement at any time.

Payment Method:

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Credit Card Information

Account No:
3-Digit Security Code:
Expiration Date:
Name of Card Holder:

Electronic Funds Transfer Authorization

Account Type:
Bank Name:
Bank Account No:
Bank Routing No:
Name of Account Holder:

This donation is being made:

In Honor of

In Memory of
Name:
Please Notify:

Notification of gifts is sent immediately, the amount is kept confidential.
Address:
City:
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I wish to remain anonymous.
Please send me information on planned giving.
Please send me information on leaving a gift in my will.
Please send me information on giving a gift of stock.

All contributions are tax deductible. Thank you for your gift.