Text Size: A- A+ Facebook Twitter LinkedIn YouTube

Ways to Give

Ways to Give

Donation Form

This donation form can be completed, printed, and then either mailed or FAXed to:

The Western Pennsylvania Hospital Foundation
4818 Liberty Avenue
Pittsburgh, PA 15224

FAX 412.578.4428

PDF version can be downloaded here.

DONOR INFORMATION: 
 Dr.    Mr.    Mrs.    Ms.    Miss    Mr. and Mrs.    Other
Name:
COMPANY INFORMATION
(This section should only be completed if the contribution is being made by a company. If you are donating as an individual, skip this section and proceed to "address.") 
Company Name:
Company Contact:
Title:
ADDRESS
Address:
City:
State:
Zip/Postal Code:
Country:
Daytime Phone:
Evening Phone:
Email Address:
GIFT AMOUNT
I would like to make a gift of: $ 
CORPORATE MATCHING GIFT
Name of Corporation:
CREDIT CARD INFORMATION
Credit Card:  VISA   MasterCard   American Express   Discover
Card Number:
Expiration Date:
Security Code:
Name on Card:
Signature: ___________________________________

I WOULD LIKE MY DONATION TO BENEFIT:

West Penn Hospital 
 The hospital's most pressing need

Other  
RECOGNITION 
Donor recognition materials should list my/our name as 

 		 This gift is anonymous.
 
My/our gift is being given in memory of 
My/our gift is being given in honor of 
Please notify the following person(s) that a honor/memorial gift has been made:
 Dr.    Mr.    Mrs.    Ms.    Miss    Mr. and Mrs.    Other
Name:
Address:
Address:
City:
State:
Zip/Postal Code:
Country:
Please list my/our name as:
Special Message: 

 

 

X
West Penn Allegheny Health System
Tell us who you are:

What areas do you use on our website?*
(select more than one if it applies)











Did you find what you were looking for?


Would you refer others to our website?

Can we contact you for future questions?

CAPTCHA math question:* 6 + 1 =

Thank you for completing the West Penn Allegheny Health System website survey.
We value your feedback and comments.