HIA Hospice - Acceptiva

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Every donation makes a difference.
For additional information on types of gifts that best fit your circumstances,
visit www.hiahealth.org/get-involved/give

Donation Levels

$500

$250

$150

$100

$50

Other Amount

Choose A Frequency

Recurring Frequency:

I would like to add 3% to my gift to help offset credit/debit processing costs.

Fund Information

Gift Designation: *

Special Instructions:

Donor Information

First Name: *

Last Name: *

Organization:

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Tribute Information

Tribute Gift Type:

Please select from the list above.

Honoree Name:

Gift Notification

Name:

Address:

City:

State:

Zip Code:

Message or Instructions

HIA Health Newsletter

I would like to receive updates from HIA Health through our bi-monthly HEARTfelt newsletter. When you sign-up, you’ll receive information on upcoming events, opportunities for support, caregiver resources and more.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *