Donation & Membership Form

STEP 1. Personal Information

First Name: *

Last Name: *

Address: *

City: *

Province or State: * Enter "N/A" if not applicable

Country: *

Postal or Zip Code: *

Email: *

Telephone: *

Fax:

Company Name:

Please complete this field if the donation is on behalf of a company or corporation.

STEP 2. Special Requests

My Gift is for: *

Other

Hospice Programs:

Please specify what program you would like your gift to be allocated to.

Memorial Gift Information

My Gift is in Memory of:

Please send notification of my memorial gift to:

First Name:

Last Name:

Address:

City:

Province or State:

Country:

Postal or Zip Code:

STEP 3. Donation Amount & Optional Membership

Please accept my donation of:

Donation Amount: * $ CAD

Include Membership Fee: *

I do not wish to become a member of the Society

I wish to become a member of the Society

A $20.00 membership fee will automatically be added to your donation.

STEP 4. Tax Receipt

A tax receipt will be sent to the donor address specified in Step 1 above. If you wish the tax receipt to be sent to a different address, please indicate below.

Tax Receipt Address: *

Send tax receipt to the address indicated above

Send tax receipt to a different address