West Valley Hospital Foundation

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Yes, I'd Like To Help Support ...
Please print this form, complete and mail to address below.

West Valley Hospital Foundation

Mr. and Mrs. Mr. Mrs. Ms. Miss Dr.

NAME

ADDRESS

CITY

STATE ZIP CODE

PHONE

Please Accept A Gift Of:

$1,000	$500	$250	$100
Other $ ________________________________________

Check enclosed payable to the West Valley Hospital Foundation
Charge to my Visa/Mastercard.

CARD NUMBER EXPIRATION DATE

CARD HOLDER SIGNATURE

Please Direct this Gift Toward:
Building & Equipment
Community Outreach
Emergency and Outpatient Medicine
Rehabilitation
Scholarships and Professional Development
Where the Need is Greatest

If Your Gift is in Tribute of Someone:
In Honor Of
In Memory Of

NAME

NAME OF PERSON TO NOTIFY OF YOUR GIFT

ADDRESS

CITY

STATE ZIP CODE

Please send me more information about how I can include West Valley Hospital Foundation in my estate plans.

Please mail this form completely filled out to:

West Valley Hospital Foundation
P.O. Box 378
Dallas, OR 97338

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West Valley Hospital Foundation
503-831-3456
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