International Association for Hospice & Palliative Care

Hospice Donation Form

You can donate to hospice by completing our form below.

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Guidestar
The IAHPC is a USA 501(c)(3) Public Charity.

*=Required Field

SECTION #1  Donor Details

*How did you learn about IAHPC?:  
*Donor Name (First, Last):
*Address 1:
Address 2:
*City:
State/Prov:
*Country
Zip/Postal Code:
*Email:
Phone (include area code):


IAHPC does not distribute or sell contact information of our donors.
This information is treated as confidential and is only for our files and record keeping.

SECTION #2

Select which program you wish to allocate your donation to:
General Funds: Your donation will be allocated to pay for programs and operations based on need
Traveling Fellowship Program: Help send a professor to teach in a developing country
Traveling Scholarship Program: Help send a student from a resource poor setting to learn and train in a program, seminar or congress
Other:

SECTION #3

If donation is to be made in memory of someone, please complete this section. If not, proceed to Section 4.

In Memory of:
If an acknowledgment of the donation is to be sent to a third party, please fill in the following:
Specify amount of donation in acknowledgment?
Yes No
Please enter phrase you wish to be included in acknowledgment in text box below
Acknowledgment Phrase:
500 characters remaining.
Send acknowledgment to
Acknowledge Name:
Acknowledge Address:
Acknowledge City:
Acknowledge State/Prov:
Acknowledge Country:
Acknowledge Zip/Postal Code:
Acknowledge Email (if available):

SECTION #4

Due to credit card transactions and administrative fees, the minimum donation amount with credit card is $25 (twenty five dollars).
If you wish to donate less, please send a check made payable to IAHPC in US dollars to our office: 5535 Memorial Drive Suite F- PMB 509, Houston, TX 77007

Amount Of Donation To IAHPC

All donations are made in $US funds
Option 1 – One time donation of $
Option 2 – Ongoing Monthly donation of $
Option 2 – Ongoing Quarterly Donation of $
Option 2 – Ongoing Yearly Donation of $
*Name as it appears on Card:
Credit Card Type:
Visa
MasterCard
American Express
*Credit Card Number (no spaces):
*Expiration Month:  
*Expiration Year:  
*CVV:
CVV number: For Visa/Mastercard, the three-digit CVV number is printed on the signature panel on the back of the card immediately after the card's account number. For American Express, the four-digit CVV number is printed on the front of the card above the card account number.
If the billing credit card address is not the same as the one entered below, please complete the spaces with the corresponding information.
*Cardholder's billing Address:
*Cardholder's City:
Cardholder's State/Province:
Cardholder's Zip Code:
*Cardholder’s Country:
*Cardholder’s email:
Is a receipt required for tax purposes?:
Yes No
Comments:
300 characters remaining.
Yes
*I agree to the amount stated below to be charged to my credit card
*Total Donation (US Dollars)