Ui Health Care In Kind Donation Form
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1UI Health Care In-Kind Donation Form
Date* _______________________________________ Time __________________________
Name of Organization _________________________________________________________
(if applicable)
Name* _____________________________________________________________________
Parent or Guardian ___________________________________________________________
(if donor is under 18 years of age)
Street Address* ______________________________________________________________
City, State, Zip* ______________________________________________________________
Phone* __________________________ Email _____________________________________
Donation Description* _________________________________________________________
(include quantity, estimated hours for homemade items)
___________________________________________________________________________
Estimated Monetary Value _____________ Number of Individuals Involved _______________
(if applicable)
Drop-off Location/Additional information ___________________________________________
___________________________________________________________________________
For more information about in-kind donations, call (319) 467-8087,
or visit our website at
For Office Use Only:
Photo Taken
Yes
No
Consent
Yes
No
Date Thank You Written _______Written By ________________________________________
Form completed by _____________________ Entered Into “Volworks” By _________________
UI Health Care • 200 Hawkins Drive, Iowa City, Iowa 52242 • 800-777-8442
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Parent category: Business