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Diamond Children’s Medical Center

Please complete the following information, print, sign and either:

Mail to: Diamond Children's Medical Center, 655 E. River Rd., Tucson, AZ 85704

Fax to: (520) 694-42= 11.

You will receive a receipt for your tax-deductible donation by mail in a= few days.
Download a printable version of this form here.

I wan= t to make a tax-deductible gift of $ _________________

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For Y= our Tax Receipt:

<= ![endif]>Mr. & Mrs.=

<= ![endif]>Miss

<= ![endif]>Mr.

<= ![endif]>Mrs.

<= ![endif]>Ms.

<= ![endif]>Dr.

First= Name: ___________________________________= ___

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Middle Initial: ______________________________________ = ; &n= bsp; = ; <= /span>

Last Name: ______________________________________ &= nbsp; &nbs= p; &= nbsp;

Compa= ny / Organization Name (if applicable): ______________________________________

Addre= ss Line 1: __________________________= ____________ &= nbsp; &nbs= p; &= nbsp;

Addre= ss Line 2: ______________________________________&n= bsp; = ; &n= bsp; = ;

City:= ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

State= : ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Zip:<= span style=3D'mso-spacerun:yes'> ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Count= ry _____________________________= _________ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Phone= 1: __________________________________= ____ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Phone= 2: ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Email= : ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Fax:<= span style=3D'mso-spacerun:yes'> ___________________________________= ___ &= nbsp; &nbs= p; &= nbsp; &nbs= p;

Please keep me updated about Diamond Children’s Medical Center= by email.

I have enclosed a check.

<= ![endif]> I wish to donate by credit card.

Credi= t Card Type:

<= ![endif]> = &nb= sp; American Express

<= ![endif]> = = MasterCard

<= ![endif]> = &nb= sp; VISA

<= ![endif]> = &nb= sp; Discover

Card = Holder Name: _____________________________= _________ &= nbsp; &nbs= p; =

Credi= t Card Number: _____________________= _________________ &= nbsp; &nbs= p; =

Credi= t Card Expiration Month: ___________= ___________________________ &= nbsp;

Credi= t Card Expiration Year: _____________________________= _________ &= nbsp;

Recog= nition Preference:

<= ![endif]> = Please list my (our) name in donor recognition materials as: _______= __________________

<= ![endif]> = I would like my gift to remain anonymous.

SIGNATURE:_____________________________________________= _______ Date:_____________