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?
