Your browser does not support JavaScript!
This form cannot automatically check that you have submitted all of the required fields without JavaScript.
Please be sure to submit all required fields (marked with stars).

Cameron Memorial Community Hospital

2015 Cameron Benefit Ball
Saturday December 5, 2015
Potawatomi Inn- Pokagon State Park

The Cameron Hospital Foundation is dedicated to improving your community hospital. Through philanthropic functions, the foundation can raise money to help fund capital growth to take care of you and your family. From new equipment to the latest in technological advances, we pledge to continue serving our community with the best healthcare available.
If you have any questions prior to the event please call (260) 667-5722.
* Sponsor Name
As it should appear on recognition/promotional materials
Level of Support
* Please choose one.
* Contact Name
* Contact Phone #
* Contact Email Address
Billing Information
* Cardholder First Name
The first name of the account holder as it appears on the credit card.
* Cardholder Last Name
The last name of the account holder as it appears on the credit card.
* Amount of Payment
Format: 45.67 (Include decimal and cents. Do not use a dollar sign.)
* Card Number
* Expiration Date
* Card Code Verification Number
The three digit number on the back of your card. (Four digit code on the front of American Express.)
* Billing Postal or Street Address
* Billing City
* Billing State
* Billing Zip Code
5 digit zip code