Donations Step 1 Donation Information Donation Amount $ Gift Designation Greatest Need Big Sky Medical Center Community Outreach and Access Innovation and Excellence – Cardiac Care Innovation and Excellence Fund – Cancer Center Underinsured Women's Mammography Fund Intensive Care Unit Hospice Other Other Donation Amount Select $1000 $500 $250 $100 $50 Other Other Amount Donation Frequency One-Time GiftMonthlyQuarterlyYearlyOther For the duration of months years For the duration of quarters years Number of Years Please describe how often you would like to make payments: Donation Total: Personal or Corporate Gift? PersonalCorporate Corporation Name Step 2 Donor Information First Name* *First Name Required Middle Initial Last Name* *Last Name Required Spouse Name Address* *Address Required Address 2 City* *City Required State* Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming *State Required Zip Code* *Zip Code Required Daytime Phone* *Daytime Phone Required Home Phone Email* *Email Required Donor Listings, please list me/us as (e.g Mr. Joe Smith, Mr. and Mrs. Joe Smith) Comments or Questions Make Donation Anonymous I would like to make this donation in honor or memory of someone else. Step 3 Billing Information Payment Type Select Credit Card Automatic Bank Account Withdrawal Please bill us/me Please contact me for payment arrangements Name On Card* *Name Required Card Type* Select Visa MasterCard Discover *Card Type Required Card Number* *Card Number Required Security Code/CCV* *CVC Required Expiration Date 010203040506070809101112/2017201820192020202120222023 Card Number Expiration Date 010203040506070809101112/20162017201820192020202120222023 Download ACH form - please print and mail with a voided check) My Company Matches My Contribution Please enter your company's name and mail your completed matching gift form to Bozeman Health Foundation. Step 4 Tribute Information Tribute Type Select In Memory Of In Honor Of Footprint Order First Name Middle Initial Last Name Name Address Address 2 City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Code Please tell us why you chose to honor this person/caregiver: May we contact you about this gift in honor of your chosen person/caregiver? YesNo Is this person your physician, nurse, other hospital employee, family member or friend? "Tree of Memories" For memorial gifts of $250 or more, we welcome you to inscribe a leaf for the "Tree of Memories". Leaf Type: $1,000 (Gold)$500 (Silver)$250 (Bronze)None Inscription (70 characters available, including spaces and punctuation) "Footprint Order" In recognition of your gift of $250 or more, we will display a silver medallion, imprinted with a footprint, the honoree's name and birth date. Memorial tributes will be recognized in gold. These medallions will be displayed in the Bozeman Deaconess Hospital Family Birth Center. You will also receive a beautifully etched glass replica of ypur medallion. Footprint Color Select Pink Blue Gold Baby's Name Baby's Lbs Baby's Ozs Baby's Birth Date Please send the glass replica to: Me/UsOther Spam Check: Slide the Arrow to Unlock Slide the arrow to unlock the form.