1 Amount 2 Name 3 Payment Donation Amount $500 $250 $100 $50 $25 Other Other Amount Make this a monthly donation. Contact Information First Name Last Name Email For recognition purposes, how would you like your name(s) to appear? I would like my gift to be anonymous Billing Address Billing Address 2 City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana International Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip Code Phone Number Billing Information Name On Card Card Type Select Visa MasterCard American Express Discover Card Number Security Code Expiration Date 010203040506070809101112/2019202020212022202320242025202620272028202920302031203220332034 Comments The Internal Revenue Service recognizes Fayette County Memorial Hospital (FCMH) Foundation as Section 501(c)(3) public charity. Gifts to Fayette County Memorial Hospital Foundation are tax deductible in the U.S.A. No goods or services were forwarded or offered in exchange for this contribution. Slide the Arrow to Unlock Donate