Online Donation

Please complete this form to donate funds by credit card, check or PayPal to the Wise Regional Health Foundation. An asterisk (*) denotes required fields.

First Name *
Last Name *
Address *
City *
State*
Zip Code *
Home Phone *	e.g., (999) 999-9999
Work Phone	e.g., (999) 999-9999
E-mail Address


I wish to donate the following amount to the Wise Regional Health Foundation *
Amount: $25 $50 $100 $250 Other $

This gift is made: In honor of... In memory of... Relationship to individual named above

Please notifiy the following individual about my gift:
Name:
Address:
City, State Zip:	,

For more information, please contact:

Wise Regional Health Foundation
2000 South Highway F.M. 51
Decatur, TX 76234
Phone: (940) 626-1384
Fax: (940) 626-3937
wrhfoundation@wiseregional.com