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Helen Keller Hospital

A Star is Born

Helen Keller Hospital respects your privacy and does not rent, sell or trade any donor information. All information relating to your gift is held in strictest confidence.
* Child's Name
* Boy or Girl Boy     Girl    
* Child's Birthdate
  Child's Mother
  Child's Father
  Parent's Address
  City
  State
  Zipcode
If you are not the parents, please complete the following:
  Your Name
  Your Address
  Phone
  Fax
  Email
  Relationship to child
Payment Information:
* Card Type Visa     MasterCard    
* Card #
* Expiration Date
* V-Code (from back of card)
* Name of Cardholder
* Follow-up
Who should be contacted when your star has been installed?