Healing Quilt - Donation form

Gift Amount: _ $500 _ $100 _ $50 _ $25 Other $____

Name______________________________________________Phone_______________

Address________________________________________________________________

City, State, ZIP__________________________________________________________

Please use my gift:

In memory of ________________________________________________

Occasion_______________________________________________________________

Please send an acknowledgement to:

Name___________________________________________________________

Address_________________________________________________________

City, State, ZIP___________________________________________________

Please make checks payable to: Children’s Hospitals and Clinics Foundation.

Designate Healing Quilt.