Golf Champion's Cup Registration Form

All proceeds from the tournament support the Martha Jefferson Hospital Foundation, providing essential support programs to our frontline healthcare heroes, local patients and their families, and those most at risk in our community.

 

Donation Information
Amount:	Champion $ 10,000.00 Major $ 5,000.00 Team $ 2,000.00 Individual $ 500.00 $     *
Designation:	2022 Golf Champion's Cup Proceeds Other
Other	*
Additional Information
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending:   Ending:
Corporate:	This donation is on behalf of a company
Anonymous:	I prefer to make this donation anonymously
How would you like your name listed for publication?
Donor Information
Title:	Adm. Bishop Brig. Gen. Capt. CDR. Col. Del. Dr. Father General Gov. The Honorable Lady LCDR Lord Lt. Col. Lt. Gen. LTG Major Major General Master Miss Mr. Mrs. Ms. MSG Prof. Rear Adm. Rev. Sen.
First name:		*
Last name:		*
Country:	United States	*
Address lines:		*
City:		*
State:	<Please Select> AA AE AL AK AB AR AS AP AZ ACT BC CA CZ CO CT DC DE UK FM FL FR GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NE NV NB NL NH NJ NM NY NC ND NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VA VI VT WA WI WV WY YT	*
ZIP:		*
Phone:
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Payment Information
Cardholder's Name:		*
Credit Card Number:		*
Card Type:	Visa American Express Discover MasterCard	*
Card Expiration:	01 02 03 04 05 06 07 08 09 10 11 12  / 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041	*
Card Security Code:		*
Matching Gifts
Many employers sponsor matching gift programs and will match any charitable contributions made by their employees. If your company has a matching gift policy, please check this box and enter your employer's name below.
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Company:		*
Additional Security
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