	Required Field(s)
Please tell us about your plans:
Select at least one checkbox. I have made a provision in my will/trust to include Mercy Medical Center Merced Foundation. I will make a provision soon to include Mercy Medical Center Merced Foundation through a bequest. I have already made a planned gift to Mercy Medical Center Merced Foundation. I would like to speak to a Mercy Medical Center Merced Foundation representative about gift planning opportunities.
First Name:	Enter a valid First name.
Last Name:	Enter a valid Last name.
Date of Birth (MM/DD/YYYY):
Address:	Enter a valid Address.
City:	Enter a valid City.
State:	Select a State.
Zip Code:	Enter a valid Zip.
Email Address:
Verify Email Address:
Phone Number ((###) ###-####):
Your name(s) exactly as it should appear in recognition: (To remain anonymous, please check the box below)
	I/We do not wish to be recognized.
I/We have named Mercy Medical Center Merced Foundation as a beneficiary of my/our: (Select more than one option by holding the CTRL key)
Gift Designation: (Select more than one option by holding the CTRL key)
Date of Document (MM/DD/YYYY):Dates must be formated as MM/DD/YYYY.
Comments: