Gaylord Hospital Gift Form
Thank you for your support of Gaylord Hospital.

Please complete the following form, then print it out and mail it to:

Gaylord Hospital
Development Office
P.O. Box 400
Wallingford, CT 06492

Personal Information
First Name
Last Name
Address
City
State
Zip Code
Phone
Email
Business Information
Employer
Title
Street
City
State
Zip
Phone
Email
Donation Information
This gift is unrestricted.
Please direct my gift to the following department or program:
This gift will be matched by my/my spouse’s employer:
This gift is in honor of:
Relationship to honoree:
Acknowledge to:
First Name
Last Name
Address
City
State
Zip
This gift is in memory of:
Acknowledge to:
First Name
Last Name
Address
City
State
Zip
Credit Card Information
Credit Card (MC, VISA):
Expiration: / (ex. 05/06)
Amount: $ (ex. $75.00)
Contact Information
Please contact the Development Office at (203) 284-2881 if you have any questions regarding your gift. Mail this form to:

Gaylord Hospital
Development Office
P.O. Box 400
Wallingford, CT 06492