Dr. Rose Guercia Memorial Scholarship Donation Form -

I would like to make a donation to the Dr. Rose Guercia Memorial Scholarship
I would like to make a donation of:*
- $50.00
- $100.00
- $200.00
- Other
Or in the amount of
Please mark this donation as anonymous
- YES
- NO
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
- No
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?

Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: 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
$0.00

Locations