Gift Form

For more than a century, Lutheran Medical Center has brought together excellent medicine and passionate donors. The result is a powerful partnership that improves the health of our community. If you need any assistance utilizing this online donation form, or have any questions please call Lutheran Medical Center Foundation 303-467-4800.
* required information
Select Gift Frequency
I would like to make a one-time gift for the following amount:
:* $
I would like to make a recurring gift.
Gift Amount* # of Payments Payment Frequency Total Gift Amount
$ X = $
NOTE: This transaction will count as the first payment toward your total gift amount.
Donor Designations
Select a designation for your contribution.

NOTE: If you select "Other" you will have the option of entering in your designation at the bottom of the page.
 
Donor Information
Title:
Company Name:*
Title:*
Last Name:*
First Name:*
Middle Initial:
Suffix:
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Email:*
Business Phone:
Gender: Female   Male  
Payment Information
Payment Method
:*
:*
:*   Explain
Credit Card Type:*
                  
Credit Card Expiration:*
Billing Information
If the billing information is the same as the contact information check this box.
If not please fill out the information below:
:*
:
:*
State:
:
:*
Country:*
Tribute Information
Tribute First Name:
Tribute Last Name:
Check here if acknowledgee is same as tribute: Yes
Please acknowledge gift to:

Last Name:
First Name:
Middle Initial:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
Email:
Relationship:
Comments / Special Instructions:
If you selected "Other" in the Donor Designation dropdown, please enter where you want your funds allotted:
By clicking Submit,
your credit card will be processed