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In Honour of a Loved One
Your Personal Information
First Name
*
Last Name
*
Street Address
*
Address Line 2
City
*
Province
*
Postal Code
*
Phone Number
*
Email Address
In Memory of... (if donating to any patient who needs support, please skip this section)
Full Name
Gender
Female
Male
Donation
Donation Amount:
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Please note: tax receipts are not issued as we are a not for profit, not a registered charity.
Message Request
I would like a card sent to the family to inform them of this donation:
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Please send the following message to the family: