Secure Payment Form

I (We) would like to support the Foundation's Annual Campaign with a tax deductible contribution at the level checked below.
Gifts of $200 or more will be recognized on a display board in the hospital lobby.
List gift as from:

Name(s), Title if used, Company, Other

Contribution Amount
This contribution is to be used:
Contributions must be received by December 31st.
Donor First Name
Donor Last Name
Address 2
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
Email Address
For information, please call 716.793.2338 or 716.793.2315. Thank you!