The Laurel Society Membership Invitation

Please print your name(s) as you would like it to appear for recognition purposes in The Medical Center Foundation’s Hall of Honor located in the hospital’s North Patient Tower and all printed materials:

Name(s)     
 
Address   

City State  Zip  


Phone      


Email Address   Birthdate

Your pledge is payable over three years.  Please indicate your payment schedule:

One-time payment in     Year One   Year Two    Year Three

Installation payments:  Payment of $      Annually     Semi-annually

Payment method:

Bill my credit card today for $

Send me a payment reminder notice later.

As a measure of my commitment, I hereby pronounce my intent, without in any way legally binding my heirs or myself, to contribute to The Medical Center Foundation:

         $ (total pledge amount)

This pledge amount qualifies me for membership in THE LAUREL SOCIETY at the following level (please select one):

Notes:

My typed name below serves as my signature:

             Date: