Child Advocacy and Protection Program

Thank you for your gift.

If this is a gift in memory of or in honor of someone, please complete the Memorial and Honorary Gifts section at the bottom of this form.

Donation Information

Amount:

Gift of

$ 250.00

Gift of

$ 100.00

Gift of

$ 50.00

Gift of

$ 35.00

Other

Additional Information

Corporate:

This donation is on behalf of a company

Anonymous:

I prefer to make this donation anonymously

Comments:

I am a D-H/Geisel Employee:

Billing Information

Title:

First name:

Last name:

Country:

Address lines:

City:

State:

ZIP:

Phone:

Email:

Payment Information

Fundraising on behalf of the Children’s Hospital at Dartmouth (CHaD) is conducted by Dartmouth-Hitchcock Health, a 501(c)(3) recognized charity by the IRS (EIN#26-4812335), for the benefit of CHaD. Your gift will appear on your credit card statement as a payment to "D-HHealth Donation".

Cardholder's Name:

Credit Card Number:

Card Type:

Card Expiration:

Card Security Code:

Matching Gifts

My company will match my gift

Memorial and Honorary Gifts

Type:

Full Name of Honoree:

Please notify the following person of my gift.