John Randolph Foundation Donor Information Form

Name: Mr./Mrs./Ms./Dr. _________________________________________________

Address: ____________________________________________________________

City, State and Zip_______________________________________

Home Phone: ____________________________

Email Address: __________________________

My contribution is made:  □  In honor of    □  In memory of___________________

Please send acknowledgement of my gift to: ___________________________________

Address: _______________________

City: ___________________________

State:___________________________

Zip: ____________________________

  

Gift Amount $____________

I would like to designate my gift for use in one or more of the following areas of need in our community:

□ Hopewell-Prince George Community Health Center Endowed Fund to be used for:

       ___Unrestricted Use    ____Medical Care    ____Dental Care    ____Medication Assistance

□ Appomattox Regional Library Endowment Fund

□ Access to Health Care

□  Education

□  Mental Health/Mental Retardation/Substance Abuse

□  Prevention/Wellness

□  Quality of Life Issues

□ Beacon Theatre Endowment Fund

□  Franklin D. Boyce Health Scholarship

□  Joan Glascock Skaggs Nursing Scholarship

□  Ted P. Blanks Scholarship

□  John and Wilber Traylor Scholarship

□  Shantaram Talegaonkar, M.D. Health Scholarship

□  Honeywell Scholarship

□  Louis C. Gibbs Scholarship

□  Bobby Owen Memorial Scholarship

□  Drs. Singh and Bhuller Outstanding Educator Award

□  Gregg E. Hosack Scholarship

□  Robert C. and Dianne W. Smith Community Service Scholarship

□ Marguerite Slagle Memorial Scholarship

□ Katy Clayton Memorial Scholarship

□ Juanita and Wilson Chambers Scholarship

□ Genevieve Renn Roscher Nursing Scholarship

□ Unrestricted