Good Shepherd Hospice

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Tax-deductible donation to support Good Shepherd Hospice.

Donor Information :	(*) Required Fields. Please provide either Personal Name or Business Name.
* Donor First Name:
* Donor Last Name:
* Donor Business Name:
* Email:
* Business Phone:
* Home Phone:
* Address:
Address 2:
* City:
* State:
* Zip Code:
Country:

Donation Amount:
Amount:	$1000 $500 $250 $100 $72 $50 $36 $25
Other Amount:
My gift is given:	In memory of In honor of
(please print name):

Gift Designation:	For the Hospice Inpatient Center Fund
	To the Annual Fund
	Springtime Remembrance Appeal
	To the Family Bereavement Fund
	Tickets - Gala Kickoff – South Shore Sail- 06-26-09


Please send notification of this gift to:
First Name:
Last Name:
Business Name:
Business Phone:
Home Phone:
Address:
Address 2:
City:
State:
Zip Code:
Country:

We do not share our donor names with other organizations.

© Copyright 2006, Good Shepherd Hospice, A Member of Catholic Health Services of Long Island