Healthcare Philantrophy - Printable Donations Form

To make your gift to St. Luke's, please print, and complete this form. You may send it with your payment to the address above.

Donor Name:

____________________________________

Address:

____________________________________

City/State/Zip:

____________________________________

Phone:

____________________________________

E-mail:

____________________________________

Enclosed is my gift of:

___$25

___$50

___$100

___$250

___$500

___$1,000

Other $________

Method of Payment:

___Check Enclosed ___Credit Card

Credit Card Type:

___Visa ___MasterCard ___American Express ___Discover

Number: ___________________________

Expiration: ____________

Name as it appears on card:

__________________________________

Memorials and Tributes

This gift is made in memory of:	____________________________________
This gift is made in honor of:	____________________________________

We will promptly acknowledge your memorial or tribute gift and send an appropriate card to the person indicated below. The amount of your gift will not be mentioned.

Name:

____________________________________

Address:

____________________________________

City/State/Zip:

____________________________________

Your name as it will appear on notification:

____________________________________

Please apply my donation to the following St. Luke's fund: (Choose One)

___	Where Most Needed	___	Nursing Excellence
___	Cancer - Melanoma Center	___	Orthopaedics
___	Cancer - Texas Cancer Institute	___	Palliative Care
___	Cardiology	___	Pastoral Care
___	Diabetes	___	Perinatal Care
___	Good Shepherd Fund	___	St. Luke's Episcopal Health Charities
___	Health, Hope and the Human Spirit: A	___	Stroke/Neurology
	Campaign for the Future of St. Luke's	___	Woodlands - Where Most Needed
___	Liver Health	___	Woodlands - Good Shepherd Fund
___	Nursing Education	___	Woodlands - Pediatrics

May we recognize your gift by listing your name in our publications? ___ Yes ___ No

My name should appear as _______________________________________

For more information, please contact St. Luke’s Office of Healthcare Philanthropy at
832-355-6822.

St. Luke’s Episcopal Health System is a nonprofit organization. Gifts to St. Luke’s are tax deductible to the extent allowed by law.