Quality service from
people who care,
close to home
GIVING OPPORTUNITIES DONATION FORM

Your gift to Johnson Development Fund, Inc., will support the quality care, programs and services provided by the members of Johnson Health Network. You may designate your gift to be used in a special way by selecting one of the categories listed below. Your gift will be designated to the program you select.

When you have selected the program you would like to support, please complete the Gift Information, Donor Information, and Credit Card Information sections which follow and submit your form online using our secure server. If you would prefer, you may also print out a copy of this form and mail it to the following address:

Johnson Development Fund, Inc.
P.O. Box 548
Stafford Springs, CT 06076-0548

For more information, please call Johnson Development Fund, Inc., at (860) 684-8109 or (860) 749-2201, extension 8109.

Please select below the giving opportunties of your choice:
    Johnson Memorial Hospital
    		"ExpandE.D. to Meet Our Growing Needs" Campaign for the renovation and expansion of the Emergency Department
    		General Use

    Other (please indicate department or service you
    would like to support):

    Johnson Surgery Center
    		Giving Appeal for recovery room furniture
    		General Use

    Other (please indicate department or service you
    would like to support):

    Evergreen Health Care Center
    "Let Us Entertain You" Appeal
    		Spirtual Care Chapel Fund
    		General Operating Fund
    		Recreation Programs
    Other (please indicate department or service you would like to support):

    Home & Community Health Services, Inc.
    		"Caring for Tomorrow, Today" Endowment Campaign
    		Hospice Program
    		Hospice Tree of Life Appeal (seasonal appeal - takes place November through January)
    		General Use
    Other (please indicate department or service you would like to support):

    Phoenix Community Cancer Center
    		Programming through Community CancerCare
    		Educational Programs and Support Groups

    Other (please indicate department or service you would like to support):
    Gift Information

    I would like to support the quality care provided by the program selected above with my gift of:

     $ 

    		  $100  $75  $50  $25  $15

    If this gift is "in honor of" or "in memory of" a particular individual, please indicate below:
    In Honor of
    In Memory of

    Donor Information
    Dr. Mr. Mrs. Ms. Miss
    Name:
    Street:
    Apartment or Suite:
    Town:
    State:
    Zip Code:
    E-mail Adress:
    Telephone Home:
    Telephone Work:
     Please check here if you do not wish to be publicly acknowledge

    Credit Card Information
    Mastercard and Visa accepted
     Master Card     Visa
    Card Number:
    Expiration Date:
    Billing Address (if different from above):
    Street:
    Apartment or Suite:
    City:
    State:
    Zip Code:
    If you are mailing this form and would prefer to send a check, please make your check payable to Johnson Development Fund, Inc.