Your Title and Name: Mr., Mrs., Mr. & Mrs., Dr. _______________________

Address _______________________________________________________

City __________________________   State _____________  Zip __________

If your gift is in honor or in memory of someone, please complete the information below:

In Memory Of ___________________________________________________

In Honor Of ____________________________________________________

If you would like Hospice and Palliative Care of the Ohio Valley to notify the family of the person you are honoring or remembering with your gift, please give the family member's name & address below.

Name: Mr., Mrs., Mr. & Mrs., Ms., Dr. ______________________________

Address _______________________________________________________

City ________________________   State _____________  Zip ___________

Enclosed: __ Check __ Cash           Amount: $____________

PLEASE CONTACT ME WITH INFORMATION ABOUT:

PLEASE MAIL OR FAX THIS FORM WITH YOUR GIFT OR INQUIRY TO:

Hospice and Palliative Care
of the Ohio Valley, Inc.
723 Harvard Drive
Owensboro, KY 42301
Fax: (270) 926-1223

If you would like to discuss giving opportunities, please call the Foundation Office at (800) 466-5348.

THANK YOU!