Holland Hospital · Donation Form

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Donations to Holland Hospital are used to support our community outreach programs. These programs bring health care services to at-risk individuals in our own community. One-hundred percent of your gift goes to the service(s) of your choice, with no deduction for administrative costs.

In the form below, please select the service you wish to support, or select the General Fund to have your gift divided between all four programs.

Contact Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

Amount

*

$100

$50

$25

$

Donation Schedule

Memorial or Tribute Gift Information

*

Please list the memorial or tribute honoree name and program (N/A if not applicable)

Send Acknowledgement to:

First Name

Last Name

Acknowledgement address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Add 3% to my total amount to help cover the payment processing fees