Name 

Address 

City 

State 

Zip 

Phone

Donation Amount      

Method of payment Visa  Mastercard Discover

Credit card #

Expiration Date

My email address:

Special Gifts

If you wish to make your donation as a lasting tribute in memory or honor of a loved one or in celebration of a special Birthday or other significant event please fill in the section below.

My gift is in Loving Memory/Honor of  or in celebration of the Birthday/Anniversary 
of:     

Please notify the following person(s) of this gift:

Name:

Address:

City/St/Zip:

Special Note:

An Extra Gift That Makes A Difference

Would you like to help High Peaks Hospice and Palliative Care
even more during your lifetime and beyond?

Yes, I will double my gift through my employers' Matching Gift       program.

Yes, I have included High Peaks Hospice in my will.

Yes, I would like to know more about how to include High Peaks Hospice in my will.

Yes, I would like to find out how to give a gift of stock.

Yes, I would like to know about participation in Planned Giving Programs.