Memorial Health Foundation

Memorial 2020 Campaign (multi-year pledge)

Thank you for joining hundreds of supports as together, we create a new standard for healthcare through the Memorial 2020 project. To provide your Memorial 2020 campaign pledge, please complete the information below. Pledges can be payable over five years, if giving begins in 2017. If at any time you have questions, please contact the Foundation office at (937) 578-4272.

Contact Information

Country
State / Province*
Address
City
Email*
Confirm Email*
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Pledge Information

Total Pledge Amount
To be paid (please choose one) yearly, quarterly, monthly, other (please specify)
In payments of the following amount
For the following number of years (maximum of five, if payments begin in 2017)
It is our intention to make the first payment in (month and year)
It is fine to include my/our name(s) with the published list of donors? (yes or no)
Contributions of $250.00 or more will be acknowledged with a comprehensive commemorative display of campaign donors. May we include your name? (yes or no)
Name of Donor(s) as you wish it to appear in all recognition
Signature for pledge approval (please type your name)
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