Support Good Samaritan Hospital Medical Center's
Crisis Response Fund

                

Our Healthcare Heroes are counting on you!
Please complete the form below to make your donation.
Your donation will help Good Samaritan Hospital Medical Center
to meet our most critical needs now.

 

Donation Information
Amount:	$ 500.00 $ 250.00 $ 100.00 $ 50.00 Other $     *
Designation:	General Unrestricted COVID-19/Crisis Fund Other
Other	*
Additional Information
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending:   Ending:
Corporate:	This donation is on behalf of a company
Anonymous:	I prefer to make this donation anonymously
Comments:
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Valid From:	01 02 03 04 05 06 07 08 09 10 11 12  / 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020  (Maestro/Switch/Solo only)
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	Note: The Card Security Code is not required for Maestro, Switch and Solo cards.
Matching Gifts
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Tribute Information
Type:	In Memory Of In Honor Of	*
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Questions? Contact Ashley King at 631-376-3097 or Ashley.King@chsli.org. 
To make a gift by mail, use our printer-friendly version of this form and send it with your check to:

Good Samaritan Hospital Foundation
1000 Montauk Hwy.
West Islip, NY 11795
Please make checks payable to the Good Samaritan Hospital Foundation.