I want to donate to the fund of my choice

By way of recognition, the Foundation will publish the names of its donors. (Check off if you want your name to remain confidential) --- No Yes

Did you consider the possibility of planning a donation by will to the advantage of the patients of the institute? --- No Yes

Information about the deceased

In memory of

Indicate the date of death

Details of the person to notify

Do you want us to notify a family member of you donation?