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Thank you for considering an online gift to Hills & Dales. The following information is needed in order to process your gift.

* Required Fields.

Personal Information
First Name *
Middle Name  
Last Name *
Address *
Address (cont)  
City *
State *
Phone #   - -
Email Address *
Gift Information
Anonymity   I would like to remain anonymous.
Gift Amount   I would like to donate $
(Must be $10.00 or more)
Special Instructions

Please tell us more about your gift. If it is a memorial or tribute, we will send an acknowledgement of your gift to whomever you designate (please include mailing address).

In Honor / Memory of  
Person(s) to Notify  
Address (cont)  
Additional Notes  
Payment Information
Choose Payment Method * VISA MasterCard AmericanExpress
Card # (No Spaces) *
Exp. Date * /
Name on Card *
CVV2 Code [?] *
Frequency *

Monthly Contribution Consent Agreement

Please read the agreement and select one consent option below.

By choosing the monthly option I am agreeing to have a contribution made monthly to Hills & Dales. 

I will see a record each month on my credit card statement. I can discontinue this arrangement at any time by contacting Hills & Dales.

Select One Option *

Double your gift: Do you or your spouse work for a matching gift company? Many companies will match the charitable giving of their employees, so any gift you make to Hills & Dales could be doubled. Check with the human resources department of your company to find out if your company matches. If they do, obtain a matching gift form, fill it out completely and return it according to your employer’s guidelines. Some companies are now providing a downloadable matching gift form online.

  Your IP is and will be logged with this transaction.

Donation questions or comments?
Deanne Althoff, Hills & Dales
1011 Davis Street
Dubuque, IA 52001