Donation Form

Sponsor a Bed at Hospital Lumiere

Bed sponsorship level and payment interval

Amount

$145/mo. Pay for 1/4 of a bed

$300/mo. Pay for 1/2 of a bed

$600/mo. Pay for one bed for full year

Payment Frequency (Sponsorships are for the full year, regardless of payment interval)

Contact Information

First Name

Last Name

Address

City

State/Province

Zip/Postal Code

Home Phone

Work Phone

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code
Click here for CVV2 information

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.