To make a gift in support of the Foundation, please print and mail the information below to the Foundation.

Your Name __________________________________________

Address ____________________________________________

City/State/Zip ________________________________________

Gift Amount _________________________________________

This gift is:

____ Unrestricted

____ I prefer to designate my gift to:

____ Pediatrics _____ Breast Health Center

____ Cancer Care _____ Cardiology

____ Dialysis _____ Nursing

____ Building Fund _____ Other _________________

If you are contributing a Memorial to Tribute gift, please record this donation:

____ In Memory Of: _________________________________

____ In Honor Of: __________________________________

Please notify the person(s) below that their loved one has been remembered in this

special way:

Name _______________________________________________

Address _____________________________________________

City/State/Zip _________________________________________

Please make check payable and mail to:

Good Samaritan Hospital Foundation

1000 Montauk Highway

West Islip, New York 11795

Please contact the Foundation Office at (631) 376-4365 if you have any questions or would like to discuss other giving opportunities to the Good Samaritan Hospital Foundation.