For your convenience, you may make a gift to the Spencer Regional Healthcare Foundation on-line using a credit card. We will send you an acknowledgement, thanking you for your thoughtfulness. If your contribution is an honor or memorial gift, we are also happy to send an acknowledgement to the family, notifying them of your gift. If you have any questions, please contact the Foundation at 712-264-6461 or by e-mail.

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Donor Information
*Last Name
*First Name
*Address
*City
*State	--Select State-- Outside US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming --Other US-- American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico US Virgin Islands --US Military-- Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific
*Zip
*Phone
E-Mail Address
I would like my gift to go toward (Please Choose One)
The greatest need at Spencer Hospital (undesignated) Abben Cancer Center Hospice of Northwest Iowa Warner Dialysis Center Rehabilitative Services Cardio-Pulmonary Rehabilitation Inpatient Care Diagnostic Services Pediatric Rehabilitation (CAMPS program) New Beginnings Family Birth Center (Obstetrics Unit) Mental Health Services Trauma/Emergency Care Surgical Services Other
Recognition / Honor Gift (Optional)
May we publicly recognize your gift (without mentioning the amount)?	Yes No
How should your name(s) be listed for recognition?
A memorial gift is a wonderful way to pay tribute to someone who is deceased. An honor gift may be given in recognition of someone who is still living whom you would like to recognize. The person honored may be anyone - a relative, friend, co-worker, boss, caregiver, etc.
This gift is in memory of:
This gift is in honor of:
If this is a memorial or honor gift, please include a name and address to whom we can send an acknowledgement of your gift:
Last Name
First Name
Address
City
State	--Select State-- Outside US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming --Other US-- American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico US Virgin Islands --US Military-- Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific
Zip
Phone
Payment Method
*Amount:
*Credit Card Number:
*Expiration Date:	--Month-- January February March April May June July August September October November December --Year-- 2005 2006 2007 2008 2009 2010