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Wilmer Eye Institute
Wilmer Development Office, Wilmer 112
600 North Wolfe Street, Baltimore, MD 21287-9015
www.wilmer.org 410-955-2020
Charitable Giving Form
CONTACT INFORMATION:
Donors may be recognized in publications. Please print your name as you wish it to appear, including your preference
for Mr., Mrs., Ms., or Dr. Please check here if you wish to remain anonymous.
Name:
Address:
City:
Phone:(H)
THIS GIFT IS:
In Honor of:
Please send notification of this gift to:
Name:
This gift is joint with:
State:
(C)
Zip:
Email:
In Memory of:
Address:
GIFT DESIGNATION:
Please designate my gift to Dr.
Please designate my gift to the greatest area of need at the Wilmer Eye Institute.
Please designate my gift to the following area:
o
o
o
o
o
o
o
o
o
o
Angel Fund/Eye Care for the Indigent
Birdshot Research Fund
Cataract and Corneal Disease
Center for Nanomedicine
Center for Stem Cell and Ocular Regenerative
Medicine (STORM)
Center for Surgical Innovation and Education
Children’s Eye Diseases
Eye Cancer
Glaucoma
International Ophthalmology – Dana Center
o
o
o
o
o
o
o
o
o
′s work.
Low Vision Rehabilitation
KURE (Kids Uveitis Research and Education Fund)
Macular Degeneration, Diabetic Retinopathy and
Other Retinal Diseases
Neuro Ophthalmology
Next Generation Fund for Young Faculty Research
Oculoplastics and Trauma
Pediatric Ophthalmology Discovery Fund
Uveitis & Ocular Immunology
Other (Please Explain):
DONATION DETAILS:
o I have enclosed a check for $
. (Please make your check payable to Johns Hopkins.)
o I pledge $
to be paid in amounts of $
over
years.
I will begin the pledge on
/
/
(You will receive annual pledge reminders.)
o I wish to make a gift by credit card: VISA MASTERCARD AMEX DISCOVER
Card #
Exp:
Name on card:
Signature:
o My employer/spouse’s employer will match this gift. – Employer’s Name:
Gifts to Johns Hopkins Medicine are subject to the policies of the Institutions in place at the time of the gift.
Therefore, a portion of this gift will be directed to the Clinical and Academic Fund as directed by the Board of Trustees of Johns Hopkins Medicine.
A copy of the current annual financial statement may be found at www.controller.jhu.edu/pubs/financial_reports/.
A lasting legacy of your caring…
Johns Hopkins is in my/our estate plans.
Please send me information about gifts that pay me/us an income.
I would like more information on how to include Johns Hopkins
in my will.
[Type text]
MAIL THIS FORM TO:
Wilmer Eye Institute
Wilmer Development Office, Wilmer 112
600 North Wolfe Street, Baltimore, MD 21287-9015
Updated: 02/2014