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Account Information

Foundation Entity? (See Below)

Memo

Payment Information

First name

Last name

Card number

Expiration date

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Address 1

Address 2

City

State

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Zip

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You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

Number of Payments: 0

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I authorize Rooks County Healthcare Foundation to process the above payment of $. I also authorize Rooks County Healthcare Foundation to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Rooks County Healthcare Foundation prior to the payment date.

I authorize Rooks County Healthcare Foundation to process the payments as outlined in the payment schedule. I also authorize Rooks County Healthcare Foundation to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Rooks County Healthcare Foundation prior to the payment date.

***Please specify, above, the Foundation Entity you would like to donate to from this list here:
1. Use Where Most Needed
2. Foundation Undesignated
3. Rooks County Health Center
4. Rooks County Transportation Services
5. Rooks County EMS
6. Rooks County Cancer Council
7. Solomon Valley Manor
8. Redbud Village
9. Stockton Medical Clinic. ***

Thank you for choosing to donate to the Rooks County Healthcare Foundation. On behalf of the foundation and those who benefit from these donations, we express our gratitude for your generosity.

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