Planned Giving at Children's Mercy Hospital Foundation

2401 Gillham Road, Kansas City, MO 64108

(816) 234-3000

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Membership Form

Welcome to The Children's Legacy Society! Please fill out and submit this membership form. We will be in touch with you within five business days to confirm your membership. The information you provide on this form will be held in the strictest confidence by the Office of Planned Giving, subject to the authorizations you provide below.

* Indicates a required field

Name(s)*
Date(s) of birth
Address*
City*
State*
Zip*
Phone*
E-mail*

I/we have included The Children’s Mercy Hospital Foundation in my/our Will or revocable trust

A specific bequest.

Amount or value

A percentage bequest of

Estimated value $

Other (describe):

Please list any specified purpose or restrictions.

I/we have named The Children's Mercy Hospital Foundation in an irrevocable trust or life-income arrangement

Charitable Remainder Unitrust or Annuity Trust

Foundation interest

Current market value of trust $

Testamentary Charitable Lead Trust

Foundation interest

Expected payout $

Term of years

Other (describe)

I/we have made The Children's Mercy Hospital Foundation the beneficiary of

A life insurance policy

Death benefit $

Current cash surrender value $

The Foundation is

Primary beneficiary

Secondary beneficiary

(check one only)

A Qualified Retirement Plan (IRA, 401k, 403b)

Foundation interest

Current market value of plan $

The Foundation is

Primary beneficiary

Secondary beneficiary

(check one only)

Documentation

Yes, I/we will share a copy of the portion of the Will that applies to The Children's Mercy Hospital Foundation or the trust agreement or Change of Beneficiary Form (401k, 403b, IRAs, Insurance) in which the Foundation is named.

Authorization for Use of Name

I/we authorize The Children's Mercy Hospital Foundation to include my/our name(s) on the membership list of The Children's Legacy Society in Hospital publications and on public recognition devices. I/we understand that this authorization is limited to the use of my/our name(s) only, and that the type and amount of my/our gift to the Hospital will remain strictly confidential.

I/we prefer my/our membership to remain anonymous.

Security Key*

Please note: Submission of this form signifies your consent to the information provided and authorizations selected.

Children's Mercy Hospital Foundation
Office of Planned Giving
2401 Gillham Road
Kansas City, MO 64108
(816) 346-1300 | Fax: (816) 346-1377
E-mail: wstephens@cmh.edu