Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
If the number you provided is for a mobile device, would you like to opt in to mobile messaging from St. Claire HealthCare?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a St. Claire HealthCare staff member?
Yes
No
SCH Staff ID#:
Email
*
example@example.com
Please direct my gift to the following:
*
Please Select
Basic and Emergency Needs Fund
Greatest Need Fund (General Support)
Charity Care Fund
Alzheimer's Caregiver Support
Hospice Fund
Cancer Care and Oncology Fund
SAFE - Employee Assistance Fund
Other
If other, please specify.
Is this gift in honor or in memory of someone?
N/A
Honorary Gift
Memorial Gift
In honor of (name, occasion)
In memory of (name):
Would you like us to send an acknowledgement of this donation to the individual or a family member or friend of the recognized individual? (The amount will not be disclosed.)
YES
NO
To whom should we send the acknowledgement?
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to deceased (if applicable):
My gift is in response to:
Please Select
Annual Giving Campaign
Charity Care Golf Outing
Christmas Appeal
Doctors' Day
Elliott County Food Pantry Campaign
Medical Staff Giving Challenge
Signature Event
Other
If other, please specify:
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