Mercy Medical Center Transportation Fund Donation Form

HELP SUPPORT MERCY'S TRANSPORTATION FOR CANCER PATIENTS

Mercy Medical Center has had a program in place for years to support patients who face transportation barriers. As needed, we cover the costs associated with cab or Uber rides, to ensure cancer patients are able to get to the hospital for lifesaving care. It’s the right thing to do. However, as the number of cancer patients requesting transportation support has surged in recent weeks, our available resources have become quickly exhausted.

Your gift of kindness will help us continue offering this invaluable service to cancer patients who are experiencing a wide range of emotions and challenges, intensified by the onset of COVID-19. Stress and worry about transportation should not be one of them.

‌

Field Is Required Direct my gift to:

Gift Comments or Notes

Field Is Required Select Gift Amount:

$1,000.00

$500.00

$250.00

$100.00

Other

Enter amount

Gift type:

One-time gift

Recurring gift

Select a Gift Duration:

Total Gift: 0.00

Honor/Memorial Information

Yes, this gift is in honor or memory of someone.

Honor Gift Type:

Honoree Full Name:

Would you like to send an email to notify someone about this honor/memorial gift? Yes, I would like to send an email notification.

Send email notification on:Select month of credit card Select Expiration Year

Recipient email addresses (separated by commas):

Available Design:

Subject Line:

Personal Message:

Yes, please send me a copy of this email notification.

Donor Information

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Prof. Suffix:

Street Address:

Apt/Box/Unit/Suite:

City:

State/Province:

ZIP/Postal code:

Country:

Phone Number:

Phone Type:

Email Address:

Yes, I would like to receive communication from Mercy Health Foundation.

Donor information is the same as my billing information.

Billing Information

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Street 1:

Street 2:

City:

State/Province:

ZIP/Postal Code:

Country:

Payment Information

Payment Method:

Credit CardBank Account

Credit Card Information:

Credit Card Type:

Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?

Bank Account Information:

Bank Routing Number: What is this?

Bank Account Number:

Verify Bank Account Number:

Account Type:

Checking
Savings

I agree to use my bank account as a payment method and authorize Mercy Health Foundation to debit my bank account to fulfill my donation commitment.

Mercy Medical Center - Baltimore, Maryland