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Blue Mountain Hospital

Hospice Donation Form

Blue Mountain Hospice welcomes online donations from members of our community. Please accept our thanks for your consideration and donations. To donate please scroll down the page and read the short directions.
All information will be kept secure and confidential. For more information on memberships or to make a donation you may also call our business office. We are a non-profit organization.

Blue Mountain Hospice would like you to know that we carefully use your donation for important needs. You may donate by providing your credit card information or by submitting your bank account routing number and checking account number in the fields below. Please only supply one set of payment information: your credit card information or your online check information. All payments are via secure server. Thank you for your support.
* Name
As It Appears On Donator's Credit Card or Checking Account.
* Billing Address
Address Where Your Credit Card or Bank Statements Are Mailed.
* City, State, Zip Code
Please Include Your City, State and Five Digit Zip Code.
* Your Email Address
Please Provide An E-mail Address.
* Amount of Your Donation
Please Specify How Much You Are Donating. Please Use Dollars and Cents.
* Method Of Payment Credit Card
  Credit Card Type
Select If You Are Paying By Credit Card.
Visa     Mastercard    
  Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
  Credit Card Expiration Date
Example: 00/00
  Name Of Your Bank
If Paying By Online Check, Please List The Local Bank Hosting Your Checking Account.
  Routing Number
Found At The Bottom of Your Check. Please Phone Your Bank If You Are Unsure.
  Checking Account Number
Found At The Bottom of Your Check. Please Phone Your Bank If You Are Unsure.
  Check Number
Make Sure You Note The Check Number Then Void The Check.
  Comments or Messages Related To Your Donation