Join WLS

Name

Address

City

State

Zip code

Phone

Email

I have provided for the Emergency Medicine Foundation in my estate plans

Type of Planned Gift Bequest Trust Life Insurance Retirement Plan Other

If other please provide detail

Unrestricted to meet the most pressing needs of EMF Restricted

If restricted, please specify (i.e. scholarship, program of your choice):

or

I/we give consent for my/our name/s to appear with others on the WLS donor wall

I/we wish to remain anonymous I/we wish my/our name/s to appear as:

You are limited to two credentials after your name

I agree to join the Wiegenstein Legacy Society