Canadian Wheelchair Foundation Donation Form
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1$150 will deliver a wheelchair to someone in need of Hope, Mobility, Freedom and Independence. Please, fill out this
donor information form completely in case we need to contact you about the delivery and distribution of wheelchairs.
Enclosed is my tax-deductible donation of
○ $150
○ $300
○ Other ________________
Council
______________________________________________________
State.
___________
Donor Name
Mailing Address
City
Province /State
Postal Code/Zip
______ ________________________
Telephone
Email
____________________________
________________________________________
For a donation of $150, you will receive a beautiful certificate of thanks with a photo of a wheelchair recipient.
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NO - I would not like to receive a Certificate with photo / or
YES - I would like to receive a Certificate with photo
Certificate will Read:
Canadian Wheelchair Foundation
wishes to thank
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Donor (as noted above) / or
other:
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□
□
in the Name of:
in Memory of:
in Honour of:
For the Gift made:
Gift Recipient Name(s):
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Please mail to me at the above address / or
Please mail directly to Gift Recipient at the following:
Address
City
Province /State
Postal Code/Zip______________________________
WHOLE CONTAINER OPTIONS: (Contact office for more information)
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$42,000 = 280 standard / 260 mountain bike tire wheelchairs to:
______
______________________________________
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$16,500 = 110 standard / 100 mountain bike tire wheelchairs to:
______
______________________________________
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○ Visa
○ MasterCard
○ American Express
Cheque enclosed / or
Credit Card:
______________________________________________________________________
Name as it appears on card
______________________________________________
Expiry Date _____________________
Card Number
______________________________________________
Signature
Canadian Wheelchair Foundation
PLEASE MAKE CHEQUES PAYABLE TO:
P.O. Box 75038, RPO White Rock
Surrey, BC
CANADA
V4A 0B1
Charitable Registration No. 88861 5606 RR0001
Fax to (604) 536-9831 / call Toll Free (866) 666-2411 / e-mail:
info@cdnwheelchair.ca
For more information, to watch videos of wheelchair distributions around the world or to donate online,
PLEASE VISIT US AT
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