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Please mail this completed form to:
St. Charles Hospital
200 Belle Terre Road
Port Jefferson, NY 11777
Att: Hospital Foundation

Please make the check payable to "St. Charles Hospital Foundation." You may specify what program or service you would like your donation to support.

All donations must be made through the St. Charles Hospital Foundation are tax deductible.

For information about making a gift to St. Charles, please call (631) 474-6465.