Community Wellness Donation Form -

Donate Towards Community Wellness

"*" indicates required fields

I would like to make a donation

Bag of Food

Price: $15.00

Round-Trip Transportation

Price: $50.00

Month of Medication

Price: $50.00

Life Saving Baby Bundle

Price: $200.00

Scholarship

Price: $500.00

Day of Our Mobile Coach on Location

Price: $2,100.00

Or in the amount of

Please mark this donation as anonymous

YES

Notes or Comments

(Ex: How did you hear about Harmony Healthcare Long Island?)

Donor Information

Name*

First Last

Company (if a corporate donation)

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Employer Match

My employer has a matching gifts program. I will provide Harmony Healthcare Long Island with the matching gift form to complete.

Yes

Please scan/email the form to info@hhli.org or mail to:
Harmony Healthcare Long Island
1600 Stewart Avenue
Suite 300
Westbury, NY 11590
Attn: Finance Department

Billing Information

Address

Is the Billing address the same as the mailing address?

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Ensure that Harmony Healthcare Long Island receives 100% of the value of my donation.

Price: $0.00

What does this mean?

Grand Total

Donate Towards Community Wellness

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