Online Donation Form

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  1. Donor Information

    (*) indicates required field

    This gift was made by:

  2. First Name*
    Please enter the donor's first name.
  3. Last Name*
    Please enter the donor's last name.
  4. Address*
    Please enter the donor's street address.
  5. City*
    Please enter the city for the donor's address.
  6. State*
    Please select the state of the donor's address.
  7. Zip*
    Please enter the zip code for the donor's address.
  8. Phone*
    Please enter the donor's phone number.
  9. Email*
    Please enter the donor's email address.
  10. Donation Information

    (*) indicates required field

  11. Type of Donation*





    Please select the type of donation.
  12. Gift Amount (NOTE: Do not include the $ sign)*
    Please enter the amount of your gift. Please enter a number only in the format xxxx.xx. Do not enter the dollar sign ($).
  13. My Gift is

    Please make a selection.
  14. In Honor or Memory of
    Please enter a name.
  15. For
    Please make a selection.
  16. Please send an acknowledgement of my gift to:

  17. Name
    Please enter a name.
  18. Address
    Please enter a street address.
  19. City
    Please enter a city name.
  20. State
    Please select a state.
  21. Zip
  22. I am interested in receiving more information on



    Please make one or more selections.
  23. Comments
    Please enter comments or questions.
  24. Payment Information

    (*) indicates required field.
    Note: All payments are in US dollars.

  25. Card Type*

    Please make a selection.
  26. Card Number*
    Invalid credit card number
  27. CCV*
    Invalid Input
  28. The CCV code is located on the back of your card

  29. Expiration Month*
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  30. Expiration Year*
    Invalid Input
  31. First Name on card*
    Invalid Input
  32. Last Name on card*
    Invalid Input
  33. Please enter the cardholder's address information below.

  34. Address*
    Invalid Input
  35. City*
    Invalid Input
  36. State*
    Invalid Input
  37. Zip*
    Invalid zip code
  38. All donations to the Indian River Medical Center Foundation are tax deductible to the extent allowed by law. Donors will be provided with a tax receipt via mail from the Indian River Medical Center Foundation to the address provided on the above form. The Indian River Hospital Foundation, Inc. DBA Indian River Medical Center Foundation is a 501(c)3 organization, EIN # 59-0760215.

    A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE [1-800-HELP-FLA (435-7352)] WITHIN THE STATE OR VISITING www.FloridaConsumerHelp.com. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. 100% OF EACH CONTRIBUTION IS RECEIVED BY INDIAN RIVER HOSPITAL FOUNDATION, INC. DBA INDIAN RIVER MEDICAL CENTER FOUNDATION (REGISTRATION #CH-1482).

  39. Total to be charged:
    0.00 USD
  40. Invalid Input

 

 

 

 

Contact Us

1000 36th Street
Vero Beach, Florida 32960
Tel: 772.226.4960
Fax: 772.563.4770

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