*Denotes Required Fields

Please contact me about giving:


*Donor's Name:                    *Donor's Last Name:
 
*Address:
 
 *City:                                     *State:                       *Zip:
      
*Phone:                                   E-mail:
  
 
*I would like to sponsor the following:
$150 Shrub
$100 Personally Engraved Brick
$50 Flowers

Enclosed is my gift of $_________________

Please charge to         VISA      MASTERCARD
Account # ____________________________ Exp Date ______

Information to be Engraved on Brick:

MAXIMUM OF 3 LINES WITH UP TO 20 CHARACTERS PER LINE.  SPACES AND PUNCTUATION ARE CONSIDERED CHARACTERS. 

PLEASE PRINT CLEARLY.

Examples
IN MEMORY OF                                     IN HONOR OF                           MR. & MRS. JOHN DOE                          MR. & MRS.
                                                            JOHN A. SMITH
*Line 1:

*Line 2:

*Line 3:


For recognition purposes for shrubs and flowers:


*In Honor  

*In Memory   


Please send acknowledgement of my gift to:


*First Name:

*Last Name:

*Address:

*City:                                     *State:                       *Zip:
         

  

Please make checks payable to SRHC Foundation. Please send this form and donation to Development Dept., St. Rita's Medical Center, 730 W. Market St., Lima, Ohio 45801-9989. Gifts are tax-deductible. If you have additional questions, please call (419) 226-9044 between 8:00 a.m. and 5:00 p.m., Monday through Friday.