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Online Donation Gift Form

Make a donation to Franklin Community Health Network using our secure form below.

If you wish to make a gift of securities, please contact the FCHN Foundation Office at 207-779-2750.

* = required

Donor Information

Please print name(s) as you wish it to appear in publications.

The names of all donors of $5 or more will appear in our Annual Report next fall. Donors of $1,000 or more will also be listed on a plaque in the Hospital lobby.

President's Circle: $5,000 and over
Founder's Circle: $2,500-$4,999
Benefactors Circle: $1,000-$2,499
500 Club: $500-$999
Donor's Club: $100-$499
Contributors: $5-$99

Please direct my gift to the following fund(s) and event(s):*

Specific Hockey Team:

I would like to donate:*


Payment Details

Mastercard/Visa - The last 3 numbers on the back of your card

Additional Information

111 Franklin Health Commons, Farmington, ME 04938 - (207)-778-6031