Celebrate a Life Form

	Yes! I would like to Celebrate a Life with a donation of $50 or more.
	Mail to HERA Foundation Box 664 Carbondale, CO 81623

Donor Information

Prefix:

_____________________

Phone (USA): _____________________
OR Phone (Intnt'l): _____________________

Work Phone: _____________________

Email: _____________________

First Name:*

_____________________

Last Name:*

_____________________

Company Name:
(if applicable)

_____________________

Address Line 1:*

_____________________

Address Line 2:

_____________________

City:*

_____________________

State/Province:*

_____________________
Other: _____________________

Country:*

_____________________
Other: _____________________

Postal Code: *

________________


Donation Information
Donation Amount:* $ __________	____ Memorial: a donation made in memory of someone. ____ Honorarium: a donation made in recognition of a living person.
In Memory/Honor of:(if applicable) _____________________

Payment Information
____ I want to pay by check and have enclosed my donation, payable to HERA Foundation. ____ I want to pay by credit card and have completed the section on the right:	Cardholder's Name: _____________________ Please enter name exactly as it appears on card. Card Number: _____________________ Type of Credit Card: __________________ Expiration Date (mo/year): _____ / _____

Acknowledgement Information
We send acknowledgement letters to all donors. For donations made in memory or honor of someone, we like to send an additional acknowledgement letter to the family. Please provide the following information, if applicable:
This information will be used solely to send a written acknowledgement of your donation or to provide requested documentation. The name and mailing address of the person(s) who should receive an acknowledgement of your donation. The addressee's relation to the person you are recognizing/honoring with your donation. Any requests for receipts, more information regarding contributions, etc.	1.________________________ ________________________ ________________________ ________________________ ________________________ 2.________________________ ________________________ ________________________ ________________________ 3.________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________


Personal information that you provide on this form will be used only to 1) send an acknowledgement of your donation, 2) send a receipt, 3) contact you regarding any errors on your donation form, 4) contact you regarding potential giving opportunities to support Ovarian Cancer research at Johns Hopkins.
If you prefer not to be contacted about potential giving opportunities please check here: _____

If you have questions about donations please call 410-502-5161.