Salem Hospital: Foundation: Donation form

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YES, I'd Like To Help Support ...
Please print this form, complete and mail to address below.

SALEM HOSPITAL FOUNDATION

Mr. and Mrs. Mr. Mrs. Ms. Miss Dr.

NAME

ADDRESS

CITY

STATE ZIP CODE

PHONE

Please Accept A Gift Of:

$1,000	$500	$250	$100
Other $ ________________________________________

Check enclosed payable to the Salem Hospital Foundation
Charge to my Visa/Mastercard.

CARD NUMBER EXPIRATION DATE

CARD HOLDER SIGNATURE

Please direct this gift toward:
Where the need is greatest
Community Health Education Center (CHEC)
Cancer Fund
Diabetes Fund
Heart Fund
Scholarship Fund

If your yift is in yribute of someone:
In Honor Of
In Memory Of

NAME

NAME OF PERSON TO NOTIFY OF YOUR GIFT

ADDRESS

CITY

STATE ZIP CODE

Please send me more information about how I can include Salem Hospital Foundation in my estate plans.

Please mail this form completely filled out to:

Salem Hospital Foundation
P.O. Box 14001
Salem, OR 97309

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