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Mayo Clinic Benefactor Recognition

On behalf of the Department of Development, thank you for your philanthropic leadership. As generous benefactors, you are cordially invited to be recognized in our Hall of Benefactors at Mayo Clinic and in our philanthropic publications.

Recognition walls in the Hall of Benefactors attractively acknowledge benefactors whose cumulative gifts total $100,000 or more. The area includes electronic recognition kiosks in displays titled Our Family of Benefactors. The Hall of Benefactors is featured in campus tours to emphasize the importance of philanthropic support.

Please complete this form so that we can recognize you appropriately and with your wishes in mind.

Benefactor information

In order to confirm who completed this form, please fill out your name and email address.

(required)First name: must have at least 0 and no more than 256 characters.The value of the First name: field is not valid.
*
(required)Last name: must have at least 0 and no more than 256 characters.The value of the Last name: field is not valid.
*
(required)Please ensure the email address is valid and follows the standard format — for example, johndoe@isp.com.
*
Preferred recognition name approval

(required)

Select one:
*
Preferred name: must have at least 0 and no more than 256 characters.The value of the Preferred name: field is not valid.
Recognition preferences

Select how you prefer to be publicly recognized at Mayo Clinic. Leaving an item unchecked indicates that you prefer to NOT be recognized in that manner.

I authorize Mayo Clinic to use my approved recognition name in:
Electronic recognition testimonial

Mayo Clinic features benefactor profiles and stories in electronic displays, websites and publications. We invite you to submit a personal message or testimonial about your relationship with Mayo Clinic and your philanthropic commitment. These stories serve as a way to honor benefactors and inspire others. Please submit a brief (2-3 sentences) message or testimonial below. Your name, statement and photograph will be displayed according to your recognition preferences above.

By submitting a testimonial, I agree that this information may be used as Mayo Clinic deems appropriate. I release Mayo Clinic and its employees from any and all liabilities that may arise from the use of such information.Testimonial: must have at least 0 and no more than 4096 characters.The value of the Testimonial: field is not valid.
Electronic recognition photo submission information

Mayo Clinic invites you to submit a personal photograph. Please email your photo to benefactorrecognition@mayo.edu.

Tips for choosing a photo to submit:

  • Size: 4" x 6" or 5" x 7" or 8" x 10" (200-300 dpi resolution).
  • Clothing: Solid colors are preferred.
  • Background: Try to avoid busy backgrounds (other people, trees and such).

Photo consent:

Thank you for your friendship and generosity!

After submitting, please do not leave this form until you see the confirmation message.

Mayo Clinic Number

Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.

If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up:

In correspondence:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In pre-appointment questionnaires

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In medical documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In dismissal summaries:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information

In several other kinds of documents:

Image of Form: Authorization for Mayo Clinic to Disclose Protected Health Information
.