Support for Children with Hearing Impairment

Thank you for your gift.

Is this gift in memory of or in honor of someone? If so, please be sure to 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:

How Did You Hear About Our Site:

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.