MedStar Georgetown University Hospital
Patio Garden Campaign
GIFT COMMITMENT – ONE-TIME GIFT FORM
YES! I would like to support MedStar Georgetown University Hospital’s Patio Garden Campaign!
DONOR INFORMATION (please print)
Name (Please note this information is where your tax receipt will be mailed)
Address
City/State/Zip Code
Phone (Home)
Phone (Cell)
Email
Department Name
I Wish to Have My Gift Remain Anonymous (Please sign your name)
GIFT INFORMATION
You may make a donation for this campaign via credit card or check. Please complete this form and mail it to: MedStar
Georgetown University Hospital, Office of Philanthropy, 3800 Reservoir Road, NW, Washington, DC 20007, Attn: Meredith
Pesci. You may also email it to Meredith.M.Pesci@gunet.georgetown.edu
Item
Brick- 4x8”
Brick- 12x12”
Cost per Item
$250
$500
Number
Purchased
Total Donation
Amount
$
$
Total Gift: $
1. I would like to make a donation via credit card in the amount of $__________________________.
Credit Card Number ________________________________________________________________ ____
Name as it Appears on Card ______________________________________________ ________________
Expiration Date _____________________ CID Number (Located on back of card) _______________ ___
____ I acknowledge that by checking this box and signing my name and date, I authorize MedStar Health to deduct this
gift amount from my credit card.
Signature
Date
2. My gift via check is enclosed in the amount of $ ______________________________________.
ENGRAVING INFORMATION
For engraving purposes, please note exactly how you would like your message to appear. Please note: All engraving
copy is subject to review.
4x8” Brick- There can be 3 lines of engraving per brick, 14 characters including spaces and punctuation in each line.
12x12” Brick- There can be 8 lines of engraving per brick, 18 characters including spaces and punctuation in each line.
If ordering additional bricks, add your message below. Please ensure the use correct number of lines and characters
based on the examples above.
If you have any questions, please call Meredith Pesci in the Office of Philanthropy at 202-444-0721.