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Donation

Gift amount:

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I would like my donation to recur:

Yes

Amount you would like to recur:

Frequency of donation:

Number of recurrences:

Date of your final recurring donation:

Please confirm recurring donation:

This gift is from myself and:

I wish to donate anonymously. (Your name will not be disclosed to family or listed in any publication.):

Yes

This donation is in memory of:

This donation is in honor of:

The donation is for a special occasion:

Please keep my gift amount confidential to the family:

Yes

I have matching funds available:

Yes
No
Not Sure

If Yes or Not Sure, who will be matching?

How did you hear about Keiro Northwest?

I would like to be placed on your email list:

Yes

I would like to be placed on your mailing list:

Yes

Please send me literature about making a will:

Yes

Keiro Northwest is included in my estate plans:

Yes

Can we help you with anything else? (Please comment here.):