Blank Children's Hospital | Gift in Kind Form

UnityPoint Clinic Urgent Care - Altoona

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UnityPoint Clinic Urgent Care - Ingersoll

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Urgent Care - Ankeny

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Urgent Care - Lakeview

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Urgent Care - Merle Hay

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Urgent Care - Southglen

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Urgent Care - Urbandale

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Virtual Care - Receive Care Now

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Blank Children's Hospital

Gift in Kind Form 

Thank you for your generous gift to Blank Children's Hospital. Please complete the form below to the best of your ability. Information listed will be utilized for tax purposes.  

 

1: Name of Organization (if applicable)
2: First Name
3: Last Name
4: Parent or Guardian (if donor is under 18 years of age)
5: Street Address
6: City
7: State
8: Zip
9: Phone
10: Email
11: Description of Items Donated
12: Number of Individuals Involved
13: Approximate Number of Hours Contributed
14: Estimated Fair Market Value of Donation
15: I would like to make this gift in honor of:
16: I would like to make this gift in memory of:
17: What inspired you to support Blank Children's Hospital?