For Our Community

Donation Form

Contribution   Giving Chapter $5000 +   New Millennium $2500 - $4999   Capital $1000 - $ 2499   Leadership $500 - $999   Patron $200 - $499   Benefactor $100 - $199   Century $1 - $99   Supporter
Amount to Donate:		$
Optional
With my gift of $200 or more, I wish to become/remain a member of the CVMC 200 Club. Please allocate $ ($200 minimum) of my total gift to the 200 Club fund. Each year, 200 Club members review and fund special requests to support the medical center.
This gift is:
In memory of / In honor of
Name:
Please notify the following individuals of my gift:
Name:
Address:
City:
State:
Zip Code:
My Information
Title:		Mr. Mrs. Ms. Mr. and Mrs. Dr. and Mr. Dr. and Mrs. Other
Name:
Address:
City:
State:
Zip Code:
Phone Number:
Payment Method
Check enclosed (please make payable to CVMC).
Please contact me regarding a stock transfer.
Please send me information about including CVMC in my will.
Check here if you wish your gift to remain anonymous.
If you or your spouse has a matching gift employer, please note the company
CVMC is an IRS 501 ( c) 3 organization. No goods or services are given in exchange for the gifts, which are tax deductible according to law.