Altoona Regional Health System - Give a Gift - Palliative Care Donation Form

Bernard A. Rosch Palliative Care Tree of Life 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

This contribution is being made: in memory of in honor of
My/Our Name(s):
Business:
Address:
City:
State:
Zip:
Telephone:
E-mail:
Please notify (without specifying amount):
Name:
Address:
City:
State:
Zip:
Leaf - $100 Donation Small Stone - $500 Donation Large Stone - $1,500
Payment Method:
Cash Amount:	$
Check Amount:	$
Sample Engraving: In Loving Memory of Persons Name From Individual or Group
Engraving should read:
Do not publish my name in your publication.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.