Name
Company/Organization (if applicable)
Phone
Email
I prefer to be contacted by:PhoneEmail
Mailing Address
Mailing Address Line 2
City
Postal Code
I would like my pledge to start on the below date. A reminder one month in advance of your pledge payment due date will be sent.
I prefer to complete my $8,000 pledge every year in:Single Annual Gift ($5,000 to SMHF, $3,000 to Hospice)Monthly Gifts ($416.67 to SMHF, $250 to Hospice)
I would like to fulfill my pledge via: Cheques to each organizationDirect Debit (enter bank details below)Credit Card (enter card details below)Gift of Securities (Foundation Office will contact)
Direct Debit:Bank Name
Transit Number:
Account Number:
Institution Number:
Credit Card: Indicate Card Type :Visa/Mastercard/AMEX
Card Number:
Expiry
CVC Number:
I agree this pledge will be in perpetuity, unless I contact both SMHF and Andy’s House Hospice to request otherwise. I understand my information will be provided with both South Muskoka Hospital Foundation and Andy’s House|Hospice Muskoka in order for each organization to process my annual donation. ($5,000 to SMHF and $3000 to Andy’s House). I will receive a charitable tax receipt from each organization.
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