SECURE ONLINE GIFT FORM (SSL Secure)

This Online Form is SSL Secure

 

 

Thank you for making a gift to help create Exceptional Care for patients at Annie Penn Hospital.

 

To designate your gift, select from the list in the Gift Purpose section. To support a  program or fund that is not listed, click Other Designation, then in the Other field type in to where you want your gift designated.

 

For assistance with this form or information about other giving opportunities, please call 336.951.4663 during business hours (8:30 am –5 pm Eastern) or email taylor.lake@conehealth.com.

 

Thank you.

 

Gift Amount

For gifts of $1,000 or more you are recognized as a member of the

Rockingham Society. Thank you.

If your gift is part of the Heritage Club, please indicate in the Additional Comments section below.

Donation Amount*
  • $25
  • $50
  • $100
  • $500
  • $1,000
  • Other $

Gift Purpose

Fund*
  • Annie Penn Annual Fund
  • Annie Penn All Cancer Patient Fund
  • Annie Penn Hospital
  • Annie Penn Cardiac Care Fund
  • PENN Nursing Program
  • Annie Penn Care Connect
  • Other Designation
Other - type designation here

Honors and Memorials

This gift is:
  • In Memory of
  • In Honor of
Honoree's Name
For the following occasion:

 

Please Notify:

Name
Address
City
State
Postal Code
Country

Your Information

 

Spouse/Partner:

Title
First Name
Middle Initial
Last Name

Enter address, city, state, and postal code

as filled with your financial institution.

Country*
Email*
Confirm Email*
Daytime Phone*
List name(s) in donor recognition materials as
Check if you want this gift to be anonymous

Payment Information

Amount*
$
Payment Type
We only accept credit/debit card payments. After you complete this form, select Submit to enter your card details into our secure transaction processor. Your submission will be processed when you finalize your secure payment information.
Additional Comments
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