Family House Donation Form

You can help patients and families who must travel to Wausau for specialty care or have a loved one in medical crisis and need help with a safe, affordable, healing place to stay.

$35 - Supports a family for one night
$105 - Supports a family for three nights
$245 - Supports a family for one week

* indicates required field

Please select a gift amount

• $35
• $105
• $245
• $500
• $1,000
• Other

ENTER YOUR GIFT AMOUNT * $.00

If a matching gift from your company or business is applicable, please send the appropriate company form(s) to:
Aspirus Health Foundation
425 Pine Ridge Blvd.
Wausau, WI 54401

Gift Information

Is your gift in memory or in honor of someone? * YesNo

Donor Information

• First Name: *
• Last Name: *
• Address Line 1: *
• Address Line 2:
• City: *
• State: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip: *
• Email Address: *
• Phone: *

Payment Information

• Name on Credit Card: *
• Card Type: * Select One VISA Mastercard Discover
• Credit Card Number: *
• Expiration Month: * Select Month (01) January (02) February (03) March (04) April (05) May (06) June (07) July (08) August (09) September (10) October (11) November (12) December
• Expiration Year: * Select Year 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
• Card Validation Code: * Last 3 digits on back of card.

Billing Information

Check this box if the your billing information is the same as the donor information you entered above.

• First Name: *
• Last Name: *

• Address Line 1: *
• Address Line 2:
• City: *
• State: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip: *
• Phone: *

Additional comments:

Step 1 of 2. Next Step: Review and confirm donation details.