Pediatric Brain Injury

Gift & Payment Information

Review Gift

Used to purchase resources to aid in the recovery of pediatric patients with a brain injury, including equipment used in rehabilitation.

Field Is Required Enter A Gift Amount:

$25.00

$100.00

$500.00

$1,000.00

Other (Minimum $10):

Enter amount

Yes, automatically repeat this gift every month.

Yes, I wish to remain anonymous on all recognition material including the donor wall and annual report.

What is your connection to Hennepin Healthcare?

Honor or Memorial Gifts

Yes, this is an honor or memorial gift. I would like you to send a notification of my donation. Note the honoree and recipient name can be the same.

Honor Gift Type:

Honoree First Name:

Honoree Last Name:

Notification Recipient Name:

Notification Recipient Street 1:

Notification Recipient Street 2:

Notification Recipient City:

Notification Recipient State/Province:

Notification Recipient ZIP/Postal Code:

Notification Recipient Country:

Message Body:

Message Closing:

Message Signature:

Yes, include the gift amount in the message.

Employer Gift Matching

Increase the effectiveness of your generous gift by having your employer match your gift.

Yes, my employer will match my gift

Employer Name (if applicable):

Billing Information

Title:

First Name:

Middle Name:

Last Name:

Suffix:

Street 1:

Street 2:

City:

State/Province:

ZIP/Postal Code:

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Email Address:

Yes, I would like to receive communication from this organization.

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Payment Information

Credit Card Information:

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Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?