Donate

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

Salutation
First Name	*
Middle Name
Last Name	*
Address	*
Address (cont)
City	*
State	*
ZIP	*
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).

Dedication
In Honor / Memory of
Person(s) to Notify
Address
Address (cont)
City
State
ZIP
Additional Notes

Payment Information

Choose Payment Method	*
	*
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 54.162.121.80 and will be logged with this transaction.

Donation questions or comments?
Deanne Althoff, Hills & Dales
1011 Davis Street
Dubuque, IA 52001
563-556-7878
dalthoff@hillsdales.org