Continuum Home Health Care Donation Form
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2Continuum Home Health Care Donation Form:
Please use this form when faxing or mailing your donation to Continuum Home
Health Care. For bequests, please contact the agency director with information
on making a bequest or a planned gift.
The agency director can be reached at 1-800-336-4040
Type of Donation: (Please Circle)
$1,000.00
Amount:
General Donation
$ 500.00
Memorial Gift
$ 250.00
In Honor Gift
Bequest
$ 200.00
Life Insurance
$ 100.00
$ 75.00
$ 50.00
$ 25.00
$
__________________
Gift To and From:
Please use this gift in the
following manner:
This donation is a gift from me.
To Provide Patient Care
This donation is a joint gift from myself and
______________________________________________.
Financial Resources for
Unfunded Programs
I would like for this to be an anonymous gift.
Community Education
This gift is in memory of: ____________________.
Staff Education
This gift is in honor of: ______________________.
Marketing so more patients
Please notify the following individuals of this gift:
can receive Continuum’s
(Name and Address):
services
Computer Equipment and
Software
Telemonitoring Equipment
This gift is unrestricted to
use where the need is greatest.
When your gift is received, we will send a special letter of notification.
The amount of the donation is never revealed. We also do not share our donor list of names with
any other organization. You will receive a separate letter of acknowledgment for your records.
Please include your Name, Address and Phone Number:
Name___________________Address____________________________________Phone
Number______________
Please make your check payable to:
Continuum Home Health Care
Please send your check and this form to
Continuum Home Health Care
Agency Director
2205 Fontaine Ave. Suite 204
Charlottesville, VA 22908-0780
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Parent category: Medical