Online Gift Designation Form

I would like to make a gift to:

I would like to make a gift for the following amount:
$50 $100 $500 $1,000 Other: $

I would like to make this gift in memory/honor of:

If you wish, Dean Foundation will notify the person(s) you name below.
(Gift amounts are kept confidential)

Name:

Address:

City:

State:

Zip:

Credit Card Information:

Name as it Appears exactly on Your Credit Card:

Address:

City:

State:

Zip:

Credit Card Number
(without spaces):

Exp. (MMYY):

Your gift is tax deductible as specified in IRS Guidelines.
Please consult your tax advisor for more details.

Your contribution of…

$50 will provide:

Two hours of interpretive services for patients
Transportation vouchers for uninsured patient attending outreach programs

$100 will provide:

One school presentation by BUCKLEBEAR on car seat safety
Car seats for two families for a year

$250 will provide:

Five teens with pediatric care at Middleton Teen Clinic
Five asthma sufferers with free medication for a year

$500 will provide:

Crash Helmet^® to give five presentations on bike safety to area schools

$1,000 supports:

The work of a volunteer nurse at BSP-Free Clinic for one year

$2,500 supports:

The work of a volunteer doctor at BSP-Free Clinic for one year