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*Donor's First Name:
*Donor's Last Name:
*Address:
Address 2:
*City:
*State:
*Zip:
*Phone:
E-mail:
*Donation Amount:
*Honoree's Name:
My gift will be matched by (name of firm):
Ask your Human Resources Office for a matching gift form and send in with your gift.
*Payment Type:
Visa Card No. ___________________________ Exp Date __________
MasterCard Card No. ___________________________ Exp Date __________
*I’d like to give:
In Memory
In Honor
Get Well
Anniversary
Birthday
Other
First Name:
Last Name:
Address:
Address 2:
City:
State:
Zip:
Phone:
E-mail:
Please include this message: (500 Characters Max.)
Please designate my contribution to be used for:
Hospice
St. Rita’s Regional Cancer Center
Behavioral Services
Oncology Unit
Intensive Care
Coronary Care
Putnam County Ambulatory Care Center
Pediatric & Adolescent Rehab
Delphos Ambulatory Care Center
Diabetes Education
Other
You will be contacted in response to your request to give a gift immediately.
While keeping the amount of your donation confidential, we will also acknowledge your gift and its occasion to the person you designate. Gifts to St. Rita’s Remembrance Fund are used to improve hospital facilities, equipment and services. All gifts are tax deductible as allowed by law.
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