_________________________________________________________________________________
La Familia Medical Center Giving Form__ I enclose a gift of $_____, payable to La Familia Medical Center.
___ Charge my one-time gift of $ _____ to my:
___ Visa ___ MasterCard ___Discover
___ Charge my monthly gift of $____ to my
Credit Card # ___________________________________ Expiration Date_______
___ I pledge a total of $__________, to be paid in full by ____________________.
Enclosed is a partial payment of $____________.
Signature_______________________________
My employer, ________________________________, has a matching-gift program.
The completed gift form is enclosed.
Name_________________________________(Please print your name as you would like it to appear in any publication.)
Street Address_________________________________________________________
City_____________________________ State_______ ZIP code_________________
Daytime Phone_____________________ Evening Phone______________________Donor Giving Levels
Friend . . . . . . . . . . . Up to $99 Contributor . . . . . . . ... .$100–$249
Supporter . . . . . .. . . $250–$499 Sponsor . . . . . . . ...... . .$500–$999
Patron . . . . . . . . . …$1,000–$2,499 Advocate………….…......$2,500–$4,999
Benefactor………..…$5,000–$9,999 Founder…….....……......$10,000 & above
Gifts to La Familia Medical Center are deductible for income-tax purposes within
the limits prescribed by law.
Your gift will make a huge difference in the quality of our patients’ lives and our
ability to serve them.
