Donor Information
First Name and MI ________________________
Last Name ______________________________
Street Address ___________________________
City, State and Zip ________________________
Daytime phone number (____) _______________


Company Information
If your gift is a business or corporate gift, please complete this section. If not, please skip to Gift Amount.
Company Name __________________________
Company Contact _________________________
Title ___________________________________


Gift Amount
[  ] I would like to make a one-time gift in the amount of $_______________.
[  ] Check Enclosed [  ] Please bill my credit card

[  ] I would like to make a monthly gift of $________________
via my
[  ] Bank Account (please enclose a voided check or deposit slip and sign below)
[  ] Credit Card

You may cancel your monthly gift at any time by writing to us.

Signature _____________________________


Credit Card Information
Only complete this information if you are using a credit card to make a gift.
Type of Card _____________________________
Credit Card Number _______________________
Expiration Date ___________________________
Name on Card ___________________________

Designation Options
I would like my contribution to benefit the following area:
[  ] Unrestricted to support the Shands Children's Hospital's most pressing needs
[  ] The new building fund
[  ] A specific program at the Shands Children's Hospital (PICU, NICU, etc.): _____________________________________


Recognition Preferences
Please list donor name(s) on donor recognition materials as: _______________
[  ] I would like my gift to remain anonymous.


Tribute Giving (optional)
I would like to dedicate my gift
[  ] in memory of ______________________
[  ] in honor of ________________________


Please send notice of my tribute gift to:
Name _____________________________
Relationship ________________________
Street Address ______________________
City, State and Zip ___________________


[  ] Please send me FREE information on including the Shands Children's Hospital in my estate plans.

Fax or mail in your donation form and information to:

Fax: 352.265.0231
OR
Shands HealthCare
Office of Development
PO Box 100326
Gainesville, FL 32610-0326

For more information, please contact Shands HealthCare Office of Development at 352.265.0784