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    YES, I want to help Lisaard and Innisfree Hospice care for residents and families
Mr./Mrs./Ms.
Address
City Prov PC Phone (home) (business)
Email
Country (cell)__________________________________
      MONTHLY DONATION
I’d like my donation directed to:
 Lisaard House  Innisfree House  Greatest need
Choose your method of payment:
 Chequing account (I’ve enclosed a void cheque) Credit Card:  Visa  MasterCard  Amex
I’d like to make a monthly donation of:  $25  $15  $10  $5
Credit Card Number
Expiry Date
Signature
Other $ __________________
    At the beginning of every month, the amount you choose will be automatically drawn from your chequing account or credit card. You will receive a consolidated receipt at the end of every calendar year. You can cancel or change your support at any time.
 SINGLE DONATION
I’d like my donation directed to:
 Lisaard House  Innisfree House  Greatest need
Choose your method of payment:
Cheque Cash
Credit Card:  Visa  MasterCard  Amex
I’d like to make a single donation of: $ __________________
Credit Card Number Expiry Date Signature
 I would like my donation to remain private.
     FUND A DAY
I’d like my donation directed to: Lisaard House Innisfree House
Choose your method of payment:
Cheque Cash
Credit Card:  Visa  MasterCard  Amex
I’d like to FUND A DAY: $2,500
In memory of ________________________Date requested____________
Credit Card Number Expiry Date Signature
    Please take a moment and verify that all your information is correct. Tax receipts are issued according to Canada Revenue Agency guidelines. Charitable No. 872749536 RR0001
 I would like to make my gift in memory of:
 Please notify their next-of-kin of my gift (must provide complete address of NOK)
Name of next-of-kin: Relationship to deceased: Address of next-of-kin:
Please return this form with your donation to:
Lisaard and Innisfree Hospice, 2375 Homer Watson Blvd., Kitchener ON N2P 0E9
Lisaard and Innisfree Hospice respects your privacy and never sells, trades, or exchanges donor names or personal information. The information collected here will be used to process your gift and issue a receipt, provide you with additional information about our work and request support from you to further our mission. If you do not wish your name to be used for one or all of these activities, check here  or call 519-208-5055 ext. 255.
Thank you for your support! For more information, please contact us at 519-208-5055 or admin@lisaardandinnisfree.com
      
























































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