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).

St. Luke Community Hospital

Foundation Dinner Tickets

St. Luke Community Healthcare Foundation
Fundraising Gala Friday September 14, 2018.

6:00pm cocktails, 7:00pm dinner followed by the live auction. Tickets are $75.00 each.

Please complete the form by entering your credit card information, including the expiration date and 3 digit security code on the back of your card. Or you are welcome to call 528-5324 or email directly to reserve your tickets.
* Name
Full Name
  Email Address
* Contact Information
Phone Number
* Number of tickets
Tickets are $75 each
  Total dollar amount for tickets $
* Add a gold star
Gold stars are $100 each. If your name is drawn, it will award you the choice of any auction item, live or silent before bidding is completed.
* Total
Total amount to be charged to credit card
Would you like a copy of your receipt?
* 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
* Contact Phone Number
Please provide a phone number where we may reach you regarding this payment