Thank you for your support.
You may print this form and mail with your gift made payable to Lodi Community Hospital Development Fund to:
Lodi Community Hospital Development Fund
225 Elyria Street
Lodi, Ohio 44254
If your employer matches charitable donations, you may be able to double or triple the amount of your gift! Please check with your employer for matching gift opportunities.
First Name ________________
Last Name ________________________
Home Address ________________________________________________
City _______________________ State ______ Zip Code __________
Home phone ______________________
E-Mail Address ____________________
Gift Amount $______________________
Make checks payable to Lodi Community Hospital Development Fund, or
pay by credit card:
Credit Card Number (Visa or Mastercard only) ___________________
Expiration Date _____________________
Please direct my gift to:
_____ Digital Mammography
_____ Unrestricted
_____ Other, please name: ___________________________________
Memorial/Tribute Gifts
I would like to give this gift:
_____ In Memory of ____________________
_____ In Honor of _____________________
Please send notification of my memorial gift to:
First Name ________________
Last Name ________________________
Home Address ________________________________________________
City _______________________ State ______ Zip Code ___________
Home phone ______________________
E-Mail Address ____________________
