WCGRH Foundation Form

Print this page and mail to West Central Georgia Regional Hospital Foundation, Inc., at
P.O. Box 12435, Columbus, Georgia 31917-2435, or turn in to Activity Therapy in Building 6 or to the Business Office in Building 1.

FOUNDATION MEMBERSHIP/DONATION FORM

I/we support the WCGRH Foundation, Inc., established to enhance the services provided for the clients and staff of West Central Georgia Regional Hospital.

[   ] Enclosed is my annual membership fee in the amount of $10.00.

[   ] Enclosed is my contribution in the amount of $______________.

[   ] Enclosed is my Lifetime Membership fee of $100.00.

[   ] In addition to my contribution, I would like to share my time and talents. Please contact me about volunteer opportunities at West Central Hospital.

Name: _________________________________

Address: _______________________________

________________________________________

Phone: [      ] ____________________________

YOUR DONATION IS TAX DEDUCTIBLE AND GREATLY APPRECIATED.