Madonna Rehabilitation Hospital : Giving & Volunteering : Foundation : Make a Gift

DONOR INFORMATION

Title:

Name:

Company Name:

Address (Line 1):

Address (Line 2):

City:

State:

ZIP:

Country:

Phone:

Fax:

Email Correspondence:

	I wish to receive future email correspondance
	I prefer to make my donations anonymously

A gift acknowledgement will be emailed to the email address specified below. We respect your desire for privacy and will not share your email address with third parties.

Email Address:

YOUR DONATION

Donation Amount:

I would like my donation to go to:

If you would like to designate a program for which your donation will be used, please specify below.

Recurring Donation:

If you select to make this a recurring donation, you may change your gift at any time by contacting us.

	I would like to make this a recurring gift each MONTH.
	This is a one-time donation.

Does your employer offer matching gifts?:

	Yes: Please send signed matching gift form to: Madonna Foundation 5401 South Street Lincoln, NE 68506
	No
	Don't Know: Please contact your company's human resources department.

HONORARY OR MEMORIAL GIFT INFORMATION

Honorary or Memorial Gift:

	I do NOT wish to make this an honorary or memorial gift.
	I would like to make this donation in HONOR of someone.
	I would like to make this donation in MEMORY of someone.

If you selected to make your donation in honor or memory of someone above, please complete the honorary or memorial recipient's information below.

I would like an acknowledgement card sent to the following individual or family:

	Yes, please send an acknowledgement.
	No, do NOT send an acknowledgement.

Recipient Name:

Recipient Date of Birth:

Recipient Date of Death:

Recipient Address:

Recipient City,State,ZIP:

Recipient Message:

If there is a specific message you would like written inside the card, please enter your message below.

Are you interested in learning about other ways to support Madonna Rehabilitation Hospital? :

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Giving & Volunteering

Foundation: Make a Gift