Northside Hospital Foundation – Donation Form

(Please print, complete, and mail or fax this form to 404.851.6891)

Name of Individual or Business Donor:_____________________________________________

Contact Name (if different from above):_____________________________________________

Address:_______________________________ City:__________ State:___ Zip Code: _______

Email:______________________________________   Phone number: (____)______________

Gift Information

Cash Gift Amount: $__________         My completed employer matching gift form is attached.

(Checks should be made payable to: Northside Hospital Foundation)

Please charge my credit card (check one):  __Visa __MasterCard __American Express

Card Number:________________________ Exp. Date:_________ Security Code:_______

Signature ___________________________________ (required for all credit card charges)

I would like my gift to support: _________________________________________________

My gift is __In Honor of:  OR __In Memory of: _________________________________

(please print tribute name)

Please Notify:

Name: ____________________________________ Email: ____________________________

Address: _____________________________ City: ________________ ST: ___ Zip _________

Non-cash Item Description: ______________________________________________________

Non-cash Item Value: $ _________ (For tax purposes, donor must determine fair value of gift.)

Your generous gift directly impacts the lives of each family served by Northside Hospital and will support initiatives such as state-of-the-art technology, research, clinical education, community wellness and charity care.

Gifts are tax deductible within the limits of the law. Thank you!

____ I would like to receive a gift envelope to help make future gifts.

____ I would like to receive information on volunteering for the hospital.

____ I would like to receive information about including Northside Hospital in my will or estate

Northside Hospital Foundation

1000 Johnson Ferry Rd.

Atlant, GA 30342-1611

(770) 667-GIVE (4483) • fax (404) 851-6891