Donation & Membership Form

Please note that this donation form requires javascript to be enabled. When you submit the form, you will be able to review the information before continuing on to the credit card processing page.

Also note that White Rock South Surrey Hospice Society will never use your email for unauthorized purposes and we will never sell or give email addresses of our donors to third parties.

If you have problems using the form, we can accept your donation by credit card if you phone our office at 604-531-7484. Thank you for your support!

STEP 1. Personal Information

First Name: *

Last Name: *

Address: *

City: *

Province or State: *

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