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General Donation Form
Amount
*
$3,000
$2,500
$1,000
$500
$300
$100
$50
$30
$3
$
Donation Schedule
One Time
Monthly
Quarterly
Yearly
Contact Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Is this donation on behalf of an organization/corporation or foundation?
Organization/Corporation
Foundation
Organization/Corporation or Foundation Name
Would you like this donation to be put towards MedWish's Ukraine Relief Efforts?
*
Yes
No - This gift is as a general donation
Is this gift in honor or memory of someone?
In Honor
In Memory
Tribute Name
*
First Name
Last Name
Who would you like to have notified of this gift?
First Name
Last Name
How would you like them to be notified?
Mail
Email
Address to Notify
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Email to Notify
Verify Email
Optional: Include a Message
I would like the amount of this donation to be shared?
Yes
No
Check here if you'd like to opt out of email updates from MedWish
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In an environmental effort to reduce paper usage, MedWish donors have the option to receive thank you letters/donation receipts via email or hard copy. Please select which manner you would prefer to receive your donation acknowledgement.
*
select one
Email
Paper
I'd like to cover the 3% fee associated with my donation so more of my contribution goes directly to MedWish
