Guardian Angel Donation Form
You have the opportunity to support Texas County Memorial Hospital or any TCMH Medical facility while paying tribute to your special healthcare provider — the individual who made the difference in your visit or stay at the hospital or medical facility. Your Guardian Angel will receive an acknowledgement letter announcing that a donation has been made in his or her honor. In addition, your Guardian Angel will receive a custom-crafted lapel pin to wear proudly.
You can donate online through PayPal or complete the form below and mail to:
TCMH Healthcare Foundation
1333 S. Sam Houston Blvd.
Houston, MO 65483
Note: For online donations, you will be redirected to PayPal’s website. You do not have to have a PayPal account to donate.
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Guardian Angel Donation Form
I would like to contribute: ___ $1,000 ___ $500 ___$250 ___$100 ___$50 ___$25 ___Other gift $ _______
My gift is being made: ___ In appreciation of my Guardian Angle healthcare provider:
Physician, Nurse or Other Caregiver: ____________________________________________
TCMH Dept.: _____________________
Your Guardian Angel will be notified of your special tribute gift.
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CREDIT CARD
Please charge $ _______________ to my ___Visa ___MasterCard ___American Express
Card No. __________________________________________________
Expiration date: _____________________
Print name as it appears on the card ________________________________________________________________
Signature _____________________________________________________________________________________
CHECK
Enclosed is my check for $____________________________, made payable to TCMH Healthcare Foundation.
(Your gift is tax-deductable to the full extend allowed by law.)
Name _____________________________________________________________________________
Email address _____________________________________________________________________________
Address _____________________________________________________________________________
State _____________________________ Zip ________________ Telephone ______________________________
EMAIL OPTION
___I would like to receive email updates from TCMH Healthcare Foundation.
Emails are sent to TCMH Healthcare Foundation subscribers only. TCMH does not sell, trade, rent or share personal information about ourusers to or with any third parties. Email updates are intended for TCMH consumers and patients 18 years of age and older.
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Questions may be sent to jgentry@tcmh.org.