Tribute Gift - La Rabida Children's Hospital

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TRIBUTE GIFTS

Provide a gift in Honor/Memorial of someone:

Donation Information

Amount:

$ 1,000.00

$ 500.00

$ 250.00

$ 100.00

$ 50.00

$ 25.00

Other

$

*

Designation:

Additional Information

Type of gift:

One-time gift
Recurring gift

Frequency:

On:
Starting: Ending:

Corporate:

This donation is on behalf of a company

Anonymous:

I prefer to make this donation anonymously

Comments:

Billing Information

Title:

*

First name:

*

Last name:

*

Country:

*

Address lines:

*

City:

*

State:

*

ZIP:

*

Phone:

*

Email:

*

Payment Information

Cardholder's Name:

*

Credit Card Number:

*

Card Type:

*

Valid From:

/	(Maestro/Switch/Solo only)

Card Expiration:

/

*

Issue Number:

(Maestro/Switch/Solo only)

Card Security Code:

help

*

Note: The Card Security Code is not required for Maestro, Switch and Solo cards.

Matching Gifts

My company will match my gift

Company:

*

Tribute Information

If you gift is in honor of or in memory of someone, please provide his or her name below.

Name:

*

First name:

Last name:

*

Type:

*

Message:

*

Click here if you would like to notify someone of your tribute gift (you will then be prompted to enter the addressee's information)

*

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