Donations - Secure Online Donation Form

Campaign/Fund Information
Campaign/Fund * URGENT CARE FOUNDATION TAX-DEDUCTIBLE CONTRIBUTION
or Select a Different Fund
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Donation Information
Donation Amount *

Payment Method *
Donate to the Urgent Care Foundation *
(Select All/None)
Thank you for supporting the Urgent Care Foundation and it’s initiatives. Your donation will help multiple causes in the urgent care industry. All donations are tax deductible.
In Honor/Memory of
If you wish to make your contribution in honor or in memory of someone, please indicate such. Please also include contact information for the person(s) you would like us to notify of your contribution.
Donor Comments
Donor Information
First Name *
Middle Name
Last Name *
Suffix
Organization
Email *
Address *
Address Cont.
City/Town *
Country *
State
Postal Code*
Phone *
     
Billing Information
[ Click here if billing address is the same as donor address ]
 *  
Organization 
Address *
Address Cont.
City/Town *
Country *
State
Postal Code*
Billing Phone *

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