$
—Please choose an option—255010025050010001500200025003000400050006000700075008000900010,000
—Please choose an option—Memorial DonationsGrateful Patients
—Please choose an option—One-Time GiftAnnual GiftThree-Year 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]
Title —Please choose an option—Dr.MissMr.Mrs.Ms.
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: —Please choose an option—YesNo
My company will match my gift
—Please choose an option—YesNo [group company-match-yes] Name of company [/group]
Is your gift in honor or memory of someone?
—Please choose an option—In Honor ofIn Memory ofOther [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.
