Steven and Alexandra Cohen Children's Medical Center
Steven and Alexandra Cohen Children's Medical Center AT NORTH SHORE

Gift Form

Date_____________________
If this a gift:
q In Honor of or q In Memory of
_______________________________________________________
Occasion________________________________________________

q My check is enclosed.    q Enclosed is a mataching gift form.
q Please send me information about how planning a gift to Schneider
Children's Hospital can provide a lifetime of income or reduced estate taxes.
(Please make checks payable to "The Center for HOPE"
q Please charge ($25 minimum)
q Master Card   q Visa   q American Express
Account #_______________________________________________
Exp. Date________  Signature_______________________________
Your Special Message: (please print)_________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Phone # (         )__________________________________________
Donor's Name(s)_________________________________________
Address________________________________________________
City______________________ State______ Zip________________
If this is a gift, please send an acknowledgement card to:
Name__________________________________________________
Address________________________________________________
City______________________ State______ Zip________________

Mail to:
Center for HOPE
North Shore-Long Island Jewish
Health System Foundation
125 Community Drive
Great Neck, New York 11021
Fax to: (516) 465-2598
Phone: (516) 465-2550