Donation Form

Donor Information

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First Name: *

Middle Name:

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Home

Business

This is a gift from my company

Please provide the following information:

Company Name:

Contact / Title:

Same as Above

Address 1:

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City:

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About my Gift

Gift Amount: *

Please designate my gift to: *

Fund for Vision

Patient Services

Education and Research

Pediatric Ophthalmology and Ocular Genetics

Endowed Funds

Please use my gift where the need is greatest

Other

Tribute Information

This gift is:

In Honor of

In Memory of

I would like to dedicate this gift to:

Gift From:

If this gift is in honor of someone, please provide the following contact information if you would like us to notify the person:

If this is a memorial gift, please provide the following information

Name of the person(s) to notify:

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Your relationship to person in whose honor the gift is made:

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Matching Gift Information

Many employers sponsor matching gift programs and will match any charitable contributions made by their employees. To find out if your company has a matching gift policy, please enter your company name below.

My company will match my gift:

Yes

I have submitted my gift information to my company’s matching gift program

Please send your company’s matching gift form to:

Development Office
Wills Eye Institute
840 Walnut Street, Suite 1540
Philadelphia, PA 19107
Attn: Lauren Lavine

Company Name:

Matching Gift Amount:

Credit Card Information

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Expiration Date: *

Security Code: *

If you have any questions or for more information, please call us at
(215) 440-3154 or email us at development@willseye.org

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