Donation Form

Donation Form
In Support of
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His or Her Name
Please send an acknowledgement to:

(without specifying amounts, honorees will receive notification that a gift has been made in their name)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Name

First NameLast Name
Email
example@example.com
For recognition purposes, how would you like your name(s) to appear?
I would like my gift to be anonymous
I give permission to publish my story

My Products*

Comments or Story
Spam Check*
The Internal Revenue Service recognizes Baxter Regional Hospital Foundation as Section 501(c)(3) public charity. Gifts to Baxter Regional Hospital Foundation are tax deductible in the U.S.A. No goods or services were forwarded or offered in exchange for this contribution.
Should be Empty:

Please send an acknowledgement to: