Please complete the following information. When you are finished, please print this page and send it along with your credit card information or check made payable to:

Hospice of Central Pennsylvania
98 S. Enola Drive
Enola, PA 17025

* Denotes Required Information

Enclosed is my gift of $200 $100 $50 $25 Other $
In appreciation of contributions of $50 or more, we will send a holiday ornament designed by our volunteers as a gift of thanks

* First Name: * Last Name:
* Address:
* City: * State: * Zip: * Country:
Phone: Fax:
E-mail:

Credit Card: VISA Mastercard American Express
Credit Card Number: Expiration Date: / /
Amount: $

Please place a light on the Tree in: Memory of Honor of
Name:

Please notify the following individual of my gift:
First Name: Last Name:
Address:
City: State: Zip: Country:

If more lights are donated, please include necessary information on the reverse of this sheet after printing it. Thank you very much.