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Puzzle Donation Form

Form for donations. $500 gets you a puzzle piece.

Donation*
- $10
- $25
- $50
- $100
- $500 (Puzzle Piece)
- Other
Other Amount
In Honor of
In Memory of
Total
$0.00
Form of Payment*
Billing
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
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Card Number Expiration Date Security Code Cardholder Name
Comments
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If you would like to mail your donation in please use this address:

Hospital for Special Care Foundation
2150 Corbin Avenue, New Britain, CT 06053

All contributions are tax deductible to the extent allowed by law.