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Homepage >> Online Donations >> Click here to print this page Click here to email this page to a friend or family
Online Giving

Please complete the following (All * marked fields are required.):

Personal Information:

Section I (must be completed)
*Title                  *First Name                       MI      *Last Name                  Suffix
 
*Street Address

Address2

*City                               *State                            *Zip

*Country
*Home Phone                                    Business Phone
(xxx) xxx-xxxx      (xxx) xxx-xxxx
*Email Address

Giving Options:

Section II
*Please charge my/our             VISA             MasterCard           Not Applicable
*Print name as it appears on card
*Card Number        *Expiration Date (month/year) / xxxx

 

Section III (Check or Money Order made payable to Huron Valley-Sinai Hospital)
 
* Enclosed is a                     Check                 Money Order               Not Applicable

 

Section IV
* I/We would like to contribute $ to Huron Valley-Sinai Hospital.
* This gift is restricted for:
My     Child       Grandchild       Self      Friend      Not applicable    has been treated at Huron Valley-Sinai Hospital

* This gift is made: In memory of In honor of On the occasion of   Not Applicable
                                 
Please notify:       Name
                                 
                                 Address
                                 
                    City       State     Zip code
Relationship to person being notified :
                                    Mother    Father    Son    Daughter    Grandparent
                                    other
 
    Yes    No     Please send me a receipt
    Yes    No     Please send me information about including Huron Valley-Sinai Hospital
                                         in my will or estate plans.
    Yes    No    Please contact me about contributing stock to Huron Valley-Sinai Hospital
 
If your company will match your gift, please mail the necessary forms to:
 
Huron Valley-Sinai Hospital
Debbie Clayton
Executive Administrative Assistant to the President
1 William Carls Drive
Commerce Michigan 48382
Phone: (248) 937 3373
Fax: (248) 937 3378
Email: dclayton@dmc.org
 
To make certain that your gift does the most possible to help our patients, receipts and acknowledgements will only be issued for gifts of $10 or more.

If you have any questions, please call Huron Valley-Sinai Hospital at (248) 937 3627

THANK YOU FOR YOUR SUPPORT!


 
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