Name
First Name
Last Name
Choose a Sponsorship Level
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Sponsor one patient for 1 event
$50.00
$
50.00
Sponsor Tia’s Hope gift bag and gift card
$100.00
$
100.00
Sponsor one patient and their family to an on premises event
$250.00
$
250.00
Sponsor two patients and their families to an on premises event
$500.00
$
500.00
Sponsor one patient and their family to an off premises event
$1,000.00
$
1,000.00
Sponsor an on premises event for an entire hospital
$5,000.00
$
5,000.00
Sponsor an off premises event for an entire hospital
$10,000.00
$
10,000.00
Sponsor all events at a hospital for one year
$25,000.00
$
25,000.00
Sponsor one year of Tia’s Hope bags and gift cards at one hospital
$50,000.00
$
50,000.00
Sponsor and entire hospital for one year
$75,000.00
$
75,000.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Email
*
example@example.com
Sponsor
Should be Empty: