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Donor Information

Donor’s Name:

I am a repeat donor. My contact information is on file. (Please enter “Name” only)

(If not repeat, please fill below):
 

Address:

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Gift Notification
 

Please notify this person of the gift (amount will be kept confidential):

 

Name

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City:

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Donation Information

Desired Fund:
 

General Donation
     

In Memory of
 

In Honor of

 

Amount to Donate:$

Check to setup a recurring payment.

Email to send Receipt:

Card Holder Information

Name as it appears on card:

Credit Card Number:

Expiration:

Card Verification Number:

  • LifeCare Medical Center
  • 715 Delmore Drive - Roseau, MN 56751
  • Phone: 218-463-2500
  • Fax: 218-463-1266
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  • Copyright 2011 LifeCare Medical Center