Circle of Care
Pledge Form
Name: _____________________________________________ Birthday: _______________________ Spouse Name: _______________________________________ Birthday: _______________________ Home Address ______________________________________________________________________ City/State/Zip: ______________________________________________________________________ Home Phone: ____________________Work: Cell:_______________________
E-mail: ____________________________________________________________________________ How do you wish to be listed in our donor recognition program? ______________________________
(Examples: Mary & John Smith, The John Smith Family, John Smith Corporation)
Please accept my/our Circle of Care pledge of $________________. I would like to pay the entire amount in a single payment. I would like to pay in installments.
(Pledges must be at least $5,000 and may be paid over a period of up to five years.)
Number of Years ____________ Starting (Month/Year) ___________ Payment amount $___________ Annually Quarterly Monthly Payment Method: Check or money order payable to St. Joseph Hospital Foundation is enclosed. Gift of stock or other asset as follows:______________________________________________ Please charge $ __________to my VISA/Mastercard Card #____________________________ Name on card:_______________________________ Expiration Date:____________________ Please use my gift as follows: Where the need is greatest Other (please specify): ____________________________________ This gift is made in honor of in memory of: __________________________________ (name) Please notify: _________________________________________________________________ (name) At (address): ________________________________ City/State/Zip: __________________________ Signature(s) _______________________________________Date ___________________________ _______________________________________Date____________________________
St. Joseph Hospital Foundation is a 501(c)(3) nonprofit organization and is registered with the Secretary of State in Olympia, Washington.
Please send to: St. Joseph Hospital Foundation, 800 E Chestnut St. 1A, Bellingham, WA 98225. Fax: (360)788-6858 / Phone: (360)788-6866 / www.thehospitalfoundation.org