Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Haxtun Hospital District

Haxtun Hospital District Foundation Donation Form

The Haxtun Hospital District Foundation welcomes online donations. We are deeply appreciative of your willingness to join us in support of our mission which is to seek, receive and administer donations and gifts for the sole benefit of Haxtun Hospital District with a priority toward further enhancing and sustaining high-quality healthcare in the hospital's service region. The amount of your contribution will be fully deductible under federal tax laws. Donors have the opportunity to designate the use of their donated funds. To make a designation selection, please choose from the check boxes provided. To complete the donation process, scroll down the page and follow the brief instructions.
All information will be kept secure and confidential. For more information on the Foundation, you may call 970-774-6123 and ask for the Director of PR/Marketing, ext. 430.

Your donation is a very valuable gift as it will help sustain the viability of the Haxtun Hospital District and in return, also help sustain the community. You may donate by providing your credit card information in the fields below.

All payments are via secure server. Thank you for your support.
* Name
Full Name of Donor
* Designation of funds DEXA Machine
Bariatric Total Care Bed
House Wide Call System
Equipment to Expand Medical Services in Fleming
Handicap Accessible vehicle for ECU Residents
Undesignated to be used for General Operating/Best Needs of the Hospital
* Your Email Address
Please Provide An E-mail Address.
  Comments or Messages Related To Your Donation
* Cardholder First Name
The first name of the account holder as it appears on the credit card.
* Cardholder Last Name
The last name of the account holder as it appears on the credit card.
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)		 $
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code