NORTHSIDE HOSPITAL – CELEBRATION OF LIGHTS * HONOR/MEMORIAL DONATION FORM
DUE BY DEC 31
Yes, I want to Be Extraordinary, Make a Difference, Help
Light Up the Trees & Support Local Patients Affected by Cancer!
•ONLINE at https://give.northside.com/lights
•CALL 770.667.4483
•EMAIL [email protected]
• Return Form by FAX to: 404.851.6891
•MAIL FORM & CHECK to: Northside Hospital Foundation, Attn: Celebration of Lights
1000 Johnson Ferry Rd NE, Atlanta, GA 30342
100% of donations to the Northside Hospital Cancer Institute help fund patient support, education,
treatment and research right here in your local community!
*Festive honor/memorial tribute cards, designed by a local student, will be sent to your loved ones.
Donor Name (please print):
Signature:
Email:
Cell Phone:
Address:
City:
ST:
ZIP:
Enclosed is My “One-Time” Gift (circle level below):
$15
$25
$50
$75
$125
$250
$500
$1000
Other:
$_______
Enclosed is My “Monthly” Credit Card Gift (circle level below):
$15
$25
$50
$75
$125
$250
$500
Other:
$_______
$1000
MASTERCARD
AMERICAN EXPRESS
Exp. Date:
Card Number:
Security Code:
Please Charge My “Monthly” Gift on the _____________ of Each Month.
Please Charge My Credit Card (circle one):
VISA
Matching Gifts: Yes! My company matches gifts of employees, spouses and retirees … I will request a
matching gift from my company and will forward the information to the Northside Hospital Foundation.
This Gift is “IN HONOR” of:
This Gift in “IN MEMORY” of:
Tribute Card Should be Sent to:
Tribute Card Should be Sent to:
Name:
Address:
City/State/Zip:
Email:
Name:
Address:
City/State/Zip:
Email: