Donate – Avita Health Foundation

Gift Information

Recurring Payroll DeductionOne-time Payroll DeductionCheckCredit CardCash GiftAppreciated Stock

Gift Designation

Please indicate one choice:

Heart & VascularCancer/OncologyWomen's & Children's Health ProgramsAvita Employee Crisis Support FundHealthcare ScholarshipsHelp Us Help Our OwnAvita Crisis Response Fund (Covid-19)Hospice & Palliative CarePatient Transportation AssistanceReading Literacy & Imagination Library (Physicians & Community Partnership)Area of Greatest Need/Campaign for AvitaOrthopedics & Sports MedicineBuckeye Paws ProgramBrick by Brick Campaign

How much would you like to contribute?

$100 per pay$50 per pay$25 per pay$20 per pay$15 per pay$10 per pay$5 per pay$2.50 per payOther

Other Amount:

Deduction Amount:

You may mail your donation to the attention of:

Avita Health Foundation
629 North Sandusky Avenue
Bucyrus, OH 44820

or send via interoffice mail to:

Avita Health Foundation
Attn. Chuck Cangelosi
Bucyrus campus

Please make checks payable to Avita Health Foundation

Donation Amount:

If you would like to purchase a memorial brick, please go to the Foundation website and use the Brick Purchase Form.

Otherwise, please go to the Foundation website and use the Online Donation Form.

Download and complete the Stock Donation Form. If you have any questions, please contact the Foundation Director at ccangelosi@avitahs.org.

You may mail your donation to the attention of:

Avita Health Foundation
629 North Sandusky Avenue
Bucyrus, OH 44820

or send via interoffice mail to:

Avita Health Foundation
Attn. Chuck Cangelosi
Bucyrus campus

Donation Amount:

Commemorative Location

Ontario Cancer CenterGalion Home Health & Hospice

Which type of brick would you like to purchase?

4x8 Brick - $2508x8 Brick - $1,00012x12 Limestone Paver - $2,50024x24 Limestone Paver - $5,000Bench Plate - $2,500

Engraving options are as follows: 4x8 bricks may have up to 3 lines of text with 20 characters per line, 8x8 bricks and bench plates may have up to 6 lines of text with 20 characters per line, 12x12 pavers may have up to 8 lines of text with 14 characters per line, and 24x24 pavers may have up to 12 lines of text with 24 characters per line.

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Donor Information

First Name:

Last Name:

Email:

Department or Name of Clinic:

Home Address:

City:

Phone:

(Optional) This is a:

In Honor of:

In Memory of:

In Tribute to:

Upon submission, an email will be sent to you requesting your approval to begin deductions.

Acknowledgement

By checking this box I agree to the payroll deductions selected on my iGive pledge form.

Acknowledgement

By checking this box I agree to the payroll deduction selected on my iGive pledge form.