Founders Fund Enrollment Form

Founders Fund Enrollment Form

Please print this form, complete all sections, include your credit card information
and signature (or enclose your check), and mail to:
Helen Hayes Hospital Foundation
Route 9W, West Haverstraw, NY 10993
and thank you for your support of Helen Hayes Hospital!

Name:
Company Name:
Address:
City:
State & Zip
Phone:
E-mail

Please indicate your choice:
	Roosevelt Club	$5,000
	Shaffer Club	$2,500
	Potter Club	$1,000
	Robb Club	$500
	Bush Club	$250
	Blagden Club	$100
	Hayes-MacArthur Club	$

	I have enclosed a matching gift form from my employer.
	I do not wish for my gift to be publicly acknowledged.
	I am interested in learning more about including Helen Hayes Hospital in my will/estate plan.

I would like to pledge		$
	monthly		quarterly
	annually
	Please send me a pledge reminder

	My check is enclosed payable to: Helen Hayes Hospital Foundation
Charge my (check one):
	Visa	Mastercard
	Discover	AMEX
Account#
Exp. Date
Signature

Helen Hayes Hospital Foundation is a publicly supported tax-exempt charitable organization. A financial statement is on file with the New York State Department of Law, Charities Bureau, 120 Broadway, 3rd Floor, New York, NY 10271.

For more information email the
HHH Foundation, Inc.

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