Donation Form

The donation form can be printed, completed and mailed.
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:
E-mail Address:

GIFT AMOUNT
I would like to make a gift of: $

CORPORATE MATCHING GIFT
Name of Corporation:

CREDIT CARD INFORMATION
Credit Card: VISA   MasterCard
Card Number:
Expiration Date:
Name on Card:
Signature: ___________________________________

I WOULD LIKE MY DONATION TO BENEFIT:

Allegheny General Hospital
The hospital's most pressing need
Allegheny Promise Employee Fund
Allegheny Singer Research Institute (ASRI)
Anesthesia Department
Cardiac Rehabilitation Program
Children's Orthopaedic Research Fund
Dialysis Unit
Gastroenterology Department
Hematology Oncology Department
Laboratory Medicine
Life Flight
Lung Center for Cancer Research
Mobile Mammography Program
Neuroscience Research
Pastoral Care Development Fund
Pediatrics Department
Social Services
Spina Bifida Clinic
Trauma Unit
Watchful Shepherd
Other

Allegheny General Hospital Suburban Campus
The hospital's most pressing need
Ambulatory Surgical Unit
Cardiac Rehab
Clinical Equipment
Intensive Care Unit
Medical Surgical Unit
Wheelchair Fund
Other

Canonsburg General Hospital
The hospital's most pressing need
Emergency Department Expansion and Renovation Project

Donations of $500 or more will be featured on the permanent bronze donor wall located in the main hallway of Canonsburg General Hospital

Forbes Hospice
The hospice's most pressing need
Forbes Hospice Respite Care
Forbes Hospice Education Fund
Other

The Western Pennsylvania Hospital - Forbes Regional Campus
The hospital's most pressing need
Cancer Care Services
Kids In Need Fund
Lifestyle Center
Other

West Penn Hospital
The hospital's most pressing need
Breast Care Fund
Burn Camp Program
Burn Trauma Unit
Cardiac Care Unit
Cardiology Research & Education Fund
Computer Assisted Orthopaedic Surgery
Emergency Department
Joslin Center for Diabetes
Neonatal Intensive Care Unit
Neurosurgical Research
Patient Care Fund
Pediatrics

Richard M. Johnston Health Sciences Library
School of Nursing Renovation Project

School of Nursing Scholarships

Touching Tomorrow Capital Campaign
Western PA Cancer Institute
West Penn Hospital Foundation
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: