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General Donation and Tribute (Honor/Memorial) Gift Form

Please complete the information below, print the completed form, enclose it in the envelope with your donation and mail to:
Altoona Regional Health System
Foundation for Life
Altoona Hospital Campus, 5th Floor Tower
620 Howard Avenue
Altoona, PA 16601

I/We enclose a gift in the amount of $ This contribution is being made: in memory of     in honor of
Donor Name(s):
Business:
Address:
City:
State:
Zip:
Telephone:
Email:
Send notification of gift to (without specifying amount):
Name:
Address:
City:
State:
Zip:
Please use this donation for: Area of greatest need     Behavioral Health Bernard A. Rosch Palliative Care Cardiology Unit Donna Jean Hospitality House Free Medical Clinic Ira B. Kron Dialysis Unit Neonatal Bereavement Oncology/Cancer Care Trauma Services     Other
Payment Method:
Cash Amount:	$
Check Amount:	$
Do not publish my name in your publication. I choose to remain anonymous.
Gifts are tax deductible to the fullest extent of the law. Thank you for your support.