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Marcus Daly Memorial Hospital

Marcus Daly Hospice Tree of Lights Donation Form

Your Support Makes a Difference!
Please fill out the form fields below to donate.
* Donor Name:
First and last name.
* Best Phone:
Example: xxx-xxx-xxxx
  Email:
  Name of Business/Organization (if applicable):
  Donor Mailing Address:
Street, City, State, and Zip
Donations: Please choose accordingly.
  Donation only. No ornament, light or public recognition, please.
  Please put a light on the Tree of Lights (minimum $5 donation per name) in memory of:
List up to 6 names.
  How many ornaments would you like to reserve (minimum donation $15 per ornament):
  Ornament Options:
Please choose an option.
I will pick up my ornament(s) at the Tree of Lights Reception on December 12th
I will pick up my ornament(s) at the Hospice Center on December 13th
I have included an additional $5/ornament in as part of my donation please deliver or mail my ornament(s) (see form field below to enter address for delivery)
My business/organization would like to be recognized as a Marcus Daly Hospice Tree of Lights Sponsor ($100 or more)
  Ornament Mailing Address
If choosing to mail ornament(s), please provide mailing address for delivery. Include Street, City, State, Zip.
Billing Information
* Total Donation
Amount charged to credit card:
* Name:
As it appears on your credit card.
* Credit Card Type:
Select Credit Card Type.
* Billing Address:
Where Your Credit Card Statements Are Mailed.
* City, State, Zip Code:
Please Include Your City, State and Five Digit Zip Code.
* Your Email Address:
Please Provide An E-mail Address.
* Your Telephone Number:
Telephone, Including Area Code, xxx-xxx-xxxx.
* Credit Card Number:
Input The 16 Digit Number Just As It Appears On Card.
* Credit Card Expiration Date:
Example: mm/yy
  Comments:
Please provide any comments regarding your donation.