Recognize Your Guardian Angel
[ ] Yes, I would like to participate in the Guardian Angel Program by making a gift to the Tracy Hospital Foundation.
Name: ___________________________________________________________
Address: __________________________________________________________
City, State, ZIP: _________________________________________________________
Email: ___________________________________________________________
My Guardian Angel
Name: ___________________________________________________________
Title (doctor, nurse, housekeeper, volunteer, etc.):
___________________________________________________________
Department/Floor/Room#: ___________________________________________________________
Reason for honoring: ___________________________________________________________
___________________________________________________________
Payment Information
Donation Amount:
[ ] $25
[ ] $50
[ ] $100
[ ] $250
[ ] $ _____ (please specify amount)
Payment Method:
[ ] Cash
[ ] Check
[ ] Credit Card
[ ] Visa
[ ] MasterCard
[ ] Discover
[ ] American Express
Cardholder’s Name:
___________________________________________________________
Credit Card Number: _________________________________________ Exp. Date: _______________
Tracy Hospital Foundation is a non-profit 501 (c) (3) organization, tax ID #: 68-0318845