Fund/Entity Choices

Please choose from the following Memorial Hospital entities to receive your gift.

Memorial Hospital Auxiliary
Memorial Hospital Community Outreach Programming
Memorial Hospital Emergency Medical Services
Memorial Hospital Foundation
Memorial Hospital General Fund
Memorial Hospital Hospice
Memorial Hospital Nurse Family Partnership
Memorial Hospital Skilled Nursing Unit
Memorial Hospital Personal Care Home Addition and Medical Office Building Expansion

Other - Please specify:  _________________________________________________


Your Name:___________________________________________

Address:____________________________________________________________________________

Email:_______________________________

Phone:_______________________________

Name(s) as I/we wish to be recognized: _____________________________________________

I wish to remain anonymous

Please make my gift:

In honor of__________________________________________________________________

In memory of_________________________________________________________________


Please send gift notification to:

Name(s): ______________________________________________________________________

Address:______________________________________________________________________

Email:________________________________________________________________________



Form of Payment:

Cash or Check Enclosed $_________________________________

Credit Name as it appears on card___________________________________




Account Number:____________________________________

Expiration Date: _____________________________________

CW/CID: __________  (3 digit number on the back of your credit card)

Amount to be charged $________________________________



BY CHECK:
Make your check payable to Memorial Hospital and mail it to:
Memorial Hospital
Attn: Foundation
91 Hospital Drive
Towanda, Pa. 18848 10003

BY PHONE:
Call the Business Office with Credit Card info at: (570) 268-2417

BY EMAIL OR FAX:
Download our Donation PDF Form and fax it to (570) 268-2392, or email it to patty.dawsey@memorialhospital.org.