Donation Form
My Gift is
In memory/honor of: ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please notify:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Your name: __________________________________________________________________________________
Address: ____________________________________________________________________________________
Phone number: _______________________________________________________________________________
(in case we have questions regarding your gift)
Please use my gift for:
____ As needed
____ Programs (cancer, education, grief)
____ Memory Diagnostic Center
____ Bed & Breakfast Program
____ Patient Care (this donation will help fulfill the $5700/month pledged stipend to St Mary's Hospice)
Thank you for supporting Countryside Hospice.