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Charitable Gift Form

Baptist Health Foundation Southeast Kentucky
1 Trillium Way
Corbin, KY 40701


Through your donations to the Baptist Health Foundation Southeast Kentucky, Baptist Health Corbin can enhance the quality of care given. The changes in healthcare in the last decade have made it increasingly challenging for Baptist Health Corbin to rely solely on traditional forms of payment, such as Medicare and managed care to provide the kind of healing environment our patients want and have come to expect.  Despite this, Baptist Health Corbin remains an excellent place to receive care and to work.

Here is my gift to support the work of Baptist Health Corbin:

◊ Other $_________       ◊ $500        ◊ $100        ◊ $50        ◊ $25


Address: ________________________________________________

City: ___________________  State: __________  Zip: ____________

Home Phone: __________________Cell Phone: _________________

Email: ___________________________________________________

Gift in Memory of: ________________________________________

My gift enclosed:

◊ Check payable to Baptist Healthcare Foundation dba Baptist Regional Medical Center

◊ Please charge my gift to ◊ Mastercard    ◊Visa    ◊ Discover

            Card Number: ________________  Expiration (mm/yy):  _____________

            Authorization Signature: ________________________________________


Please use my gift towards:

◊ Memorial and Honorary Gift

◊ The President's Fund - Greatest Need of the hospital/patient/community

◊ The Harold Mauney Cancer Fund

◊ Dr. Tae Joon Seo Memorial Endowment Fund

◊ Other: _________________________