Support Regions Hospital

Please print out, complete, and mail this form with your check or money order made out to:

Regions Hospital Foundation
640 Jackson Street, Mail Stop 11202C
St. Paul, MN 55101-2595

Thank you for your support!

Name _________________________________________________________________

Street ________________________________________________________________

City ___________________________________ State _____ Zip ________________

Telephone ______________________

E-mail _________________________________
          (must have if electing to receive Donor E-Mail)

Amount Donated ________________________________________________________

Please check here if:

_____ I prefer not to be listed publicly as a Regions Hospital Supporter
_____ I prefer not to receive the quarterly Donor E-Mail