Please fill in this form, print it out, and return it with payment to: Sutter VNA & Hospice Foundation, 1110 N. Dutton Avenue, Santa Rosa, CA 95401, or call 1-800-541-5045 for credit card donations.

Here is my gift of $ to "light up" # symbolic lights at the community celebrations. (Any amount is appreciated.)

Here is my gift of $ to purchase # collector porcelain ornament(s) for each $100 donation (please make ornament choices below):

Please write your name and address below:

Name:
Address:
City:	State:	Zip:

1. In Memory of In Living Tribute to

Notify:
Name:
Address:
City:		State:	Zip:
	Porcelain Butterfly Ornament ($100)
	Chai Hebrew Symbol of Life ($100)
Send to (if different from above):

2. In Memory of In Living Tribute to

Notify:
Name:
Address:
City:		State:	Zip:
	Porcelain Butterfly Ornament ($100)
	Chai Hebrew Symbol of Life ($100)
Send to (if different from above):

I would like to donate by:

Check VISA Mastercard $ Amount of your gift If you would like to make your credit card gift by phone, please call 1-800-541-5045
Credit Card Number:	Exp. Date:
Name on card:
Email address:	Phone:
Signature: