If you are considering a donation,
you may print and fill out this form and mail or fax it to:
Development Office
Sibley Memorial Hospital
5255 Loughboro Road, NW
Washington, DC 20016
Fax: (202) 364-8405
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Please make checks payable to Sibley Memorial Hospital.
Donation Form
Circle One: Mr. / Mrs. / Ms. / Mr. & Mrs.
Please Print
Name: _________________________________________________
Address: _______________________________________________
City: _________________________ State: ______ Zip: __________
Phone (optional): ________________________________________
My/our gift is at the following level:
___ Up to $99 Friend
___ $100 to $499 Partner
___ $500 to $999 Supporter
___ $1,000 and up Sibley Society Member
___ Lucy Webb Hayes Founders Circle for those who have included Sibley
in their estate plans.
Enclosed is my/our gift in the amount of $______________________
If this is an Honor or Memorial Gift please complete the following
Memorial Gift
Name of deceased:________________________________________
Name and address of person you wish acknowledged for your memorial gift
(spouse of deceased or other family member):
Name: _________________________________________________
Addresss: ______________________________________________
_______________________________________________________
Honor Gift
Name of honoree: ________________________________________
Address of honoree: ______________________________________
_______________________________________________________
Please send me information about gifts by will and other ways to
give
Send to this Address: _____________________________________
_______________________________________________________
_______________________________________________________
By Credit Card
Card Type: __ American Express __ Master Card __ Visa
Card Number: ____________________________________________
Amount: $___________________ Expiration Date (MM/YY): ________
Your Signature: ___________________________________________
(please fill in name and address at top of this form.)
You will receive written acknowledgement of your gift.
To speak to someone directly about your contribution,
please call 202-537-4257 Monday through Friday, 9am- 5pm.
Thank you for your support.
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