| Donor |
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| *First Name: |
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| *Last Name: |
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| *Address: |
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| *City/Town: |
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| *State: |
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| *Zip: |
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| *Email Address: |
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| *Phone Number: |
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| This gift is given: |
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In Memory of |
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In Honor of |
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Plaque information
(40 letters & spaces total) |
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*Gold level gifts also include membership to Prism, Unity's Leadership Society. Please contact Paulette Briskie at (585) 723-7877 or pbriskie@unityhealth.org for membership details.
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| Season Requested: |
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Spring – Trees will be planted on or about May 1st to coincide with Arbor Day |
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Fall – Trees will be planted on or about Oct. 1st |
Once the tree is planted, the donor will be contacted for a formal presentation.
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| *Name on Credit Card: |
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| *Credit Card Number: |
Your credit card information is secured through 128 bit SSL encryption. |
| *Security Code: |
(Last 3 or 4 digits on back of card) |
| *Expiration Date: |
(month/year) |
To pay by check: Please make checks payable to Unity Health Foundation and send to:
UNITY HEALTH FOUNDATION
1555 Long Pond Road
Rochester, NY 14626
foundation@unityhealth.org
Phone: (585) 723-7050 • Fax: (585) 723-7850 |
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Your contribution is tax-deductible to the extent of the law. You will receive an acknowledgment and receipt of your gift for tax purposes.
Unity Health Foundation is a tax-exempt, not-for-profit corporation that develops financial support for Unity Health System's programs and services. A copy of the Foundation's Annual Report may be obtained from the Office of the Attorney General, Charities Bureau, 120 Broadway, New York, New York 10271. |