Amount

    $

    Designation

    Type of Gift


    [group if-monthly-chosen]This form will process your first donation. A representative from the Memorial Regional Health Foundation will reach out to you directly to arrange your recurring donation.[/group]

    Donor Information

    Title

    First Name

    Last Name

    Address (line 1)

    Address (line 2)

    City

    State

    Zip

    Phone

    Email

    How would you like any donor recognition to be listed:

    I/We would like to remain anonymous:

    Matching Gifts

    My company will match my gift


    [group company-match-yes]
    Name of company
    [/group]

    Tribute Gift

    Is your gift in honor or memory of someone?


    [group tribute-gift-type]
    Other tribute type

    [/group]

    Honoree First Name

    Honoree Last Name

    Please Note: All donations qualify for a charitable income tax deduction and Colorado Enterprise Zone tax credit – the State of Colorado allows a 25% tax credit on your state income taxes. To qualify for tax credits, please call the Foundation office (970) 826-2424 to provide your social security number.