Tribute Lights Appeal – Donation Form Tribute Lights Appeal - 2026 URLThis field is for validation purposes and should be left unchanged.First name(Required)Last name(Required)Is this donation made on behalf of a group? If yes, let us know who it's from.Address Information:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe PhoneEmail(Required) I would not like this donation to be included in public listings: Anonymous Type of Donation(Required)In Memory Of (For those who have passed)In Honor Of (In recognition of those still with us)OutrightBrick Purchase (In Memory Of)Brick Purchase (In Honor of)Sponsor a Brick for a Hospice FamilyIn Memory Of First Name Last Name In Honor Of First Name Last Name What is your relationship to the honoree?Are there individual(s) you'd like us to notify that you made a gift in honor/memory of the honoree? Please provide us with the full name and address of the individual(s) you want us to notify.Donation Amount $25 $50 $100 $250 $500 $1,000 Other Amount Other Amount Solace Garden Brick Sizes: $150 - (4x8) Brick $250 - (8x8) Brick Please personalize your brick in the spaces below. An 8x8 brick can have up to 5 lines and a 4x8 brick can have up to 3 lines. Each brick should have no more than 20 characters per line without graphic. IF you have chosen a graphic, each brick size should have no more than 16 characters per line. NOTE: Any symbol is considered one space. For example: (dash, period, space, etc.)Line 1:Line 2:Line 3:Line 4:Line 5:If you would like a graphic on your brick, please note that this will be an additional $25. Please indicate which graphic you would like here:Add Mini Replica Brick - Price per replica $25 - (Only available at time of order) Quantity Price: $25.00 Quantity Note(s)I would like to know more about: How to include Hospice in my Will, Estate Plans, or Annuity Disbursement. Volunteer Opportunities Total You do not need a Paypal Account. Click on PayPal button and choose to Donate with Debit or Credit Card. Payment Method(Required)PayPal Checkout American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date (xx/xx) Security Code Cardholder Name
