Personal Information

Magdi Yacoub Global Heart Foundation Cairo Personal/Plaque Information Form

Please complete the form below to record your donation information as well as the names you wish to be written on the plaque.

* Required Fields

Contact Information

First Name

Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

Work Phone

Room Dedication Donation Options

Room Donation Options

$31,000 Donation – One Plaque dedicated in the name/s I provide in the field below.$62,000 Donation – Two Plaques in dedication in the name/s I provide in the field below.

* Room Donation Options is required.

Plaque Dedication Options

A Gift FromA Gift In Honor OfA Gift In Memory Of

* Plaque Dedication Options is required.

Please provide the spelling of the names you wish to be written on the plaque: