Be a Miracle Maker for the Children's Hospital

Thank you for helping children by making a gift to the University of Virginia Children's Hospital. Please use this form to make a pledge to be a Miracle Maker for the 2004 Radiothon. For more information about the UVa Children's Hospital and different ways to give, visit the UVa Children's Hospital Development Office, or visit the UVa Children's Hospital website directly.
** Required fields are marked with an asterisk *.
Gift Allocation
* Please indicate the amount you would like to give to the Radiothon (in dollars only):
$ Radiothon Miracle Maker
You are making a big difference by giving a small amount each month!
Your credit card will be billed $20 per month for 12 months ($240 per year)

Please click here and print out the form. You will need to fill out the form and either fax it to our attention or mail it in to our office. Then fill out and submit the rest of this form with the gift amount along with your personal information and any gift preference you desire. This will enable us to record your gift during the Radiothon, even if we do not recieve your form before the end of the Radiothon.
** If you do not send in your authorization to bill your credit card on a monthly basis, you will be billed monthly.

Gift Preferences
This is a joint gift. Please also credit:
Spouse Name:
Spouse Class and Year:
Please credit this gift anonymously.
This gift will be matched by

Personal Information
 
* First Name:
Middle :
* Last Name:
* Street :
 
 
* City:
* State:
* Zip:
Country
(if not U.S.)
Email Address:
Telephone:
* I am a/an:
Payment Options
This is a pledge to be billed $20 monthly for the next 12 months, total of $240.00.

Please send reminder by:

If you wish to send a check now, please direct it to:

     UVa Fund or Children's Hospital
     P.O. Box 3446
     Charlottesville, VA  22903

Exceptions:  Checks for the Jennifer Fund and the Pediatric Endowment should all be made out to Rector & Visitors.

Please only click on "Continue" once.
This form may take a few moments to process.

On behalf of all the young patients at the
UVa Children's Hospital...
Thank You!

For more information, please call
(434) 924-8432 or (800) 297-0102
during normal business hours.
Or, you may send your check directly to
UVa Children's Hospital, University of Virginia Fund
P.O. Box 3446, Charlottesville, VA, 22903.
Please make your checks payable to UVA Fund/Children's Hospital.
All gifts are tax-deductible.