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Please complete and print form, and send to address below or fax to (515) 274-1137.
On any given day, patients may be turned away because there’s no room for them. Won’t you help us make
room through your pledge and support? At the new Bright Kavanagh House, 500 more patients each year will
receive around-the-clock care and find quality of life at the end of life.
You may also download a PDF version of this pledge card here. I /we agree to contribute $ to the Lasting Memories campaign. Signature(s)________________________________________________ Date___________________ Signature(s)________________________________________________ Date___________________ Note: Gifts of $1,000 or more will be permanently recognized at The Bright Kavanagh House. If applicable, please specify how you would like your name inscribed. Please print your name(s), address, phone and email below. Please complete information on both parts of pledge form. Name(s): Address: City/State/Zip: Phone: Email: Gift Options By check My one-time donation of $ is enclosed (payable to Hospice of Central Iowa Foundation). By credit card I want to give my gift by credit card. Visa MasterCard Discover Card # ––– Exp. Date / One-time amount $ or $ per month for 12 / 24 / 36 months (circle one). or $ per quarter for 1 / 2 / 3 years (circle one). Signature________________________________________________________ By bank automatic debit Please debit my bank account for $ per month for 12 / 24 / 36 months (circle one). (We will send you a form to complete and return.) By invoice Please bill me $ (amount per invoice). Quarterly Semiannually Annually for 1 / 2 / 3 years (circle one). Company Match My company will match my gift and the appropriate form is enclosed. This gift is in memory of honor of I prefer my gift to remain anonymous
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HOSPICE OF CENTRAL IOWA FOUNDATION • 401 RAILROAD PLACE • WEST DES MOINES, IA 50265 (515) 274-3400 • www.hospiceofcentraliowa.org |