Donation Form Calgary Health Trust
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1Donation Form
(Please print)
Date: _____________________________
Donation Amount:
$_______________________
Salutation:
Mr.
Mrs.
Ms.
Miss
Donor Name: ________________________________________________________________________________________
(Individual or Organization)
Address: ____________________________________________________________________________________________
City: _____________________ Province: ____________________ Postal Code: __________________________________
Telephone: ____________________________ E-Mail:_______________________________________________________
Monthly Donations: Yes, I’d like to make a monthly commitment to the Calgary Health Trust and its vision. I authorize the
Calgary Health Trust to receive: $_______________________ each month.
Signature: _________________________________________Date:__________________________________
I prefer to make my monthly gift by credit card. (Please complete credit card information below)
Please debit my bank account. (A sample cheque marked VOID is enclosed)
Our guarantee: You can change or cancel your monthly donation at any time by contacting us at (403) 943-0615.
I may revoke my authorization at any time, subject to providing notice of 30 days. To obtain a sample cancellation form, or for more
information on my right to cancel a PAD Agreement, I may contact my financial institution or visit "I have certain
recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit
that is not authorized or is not consistent with this PAD agreement. To obtain more information on my recourse rights, I may contact
my financial institution or visit
Tribute Donation
(Circle One)
Yes
No
In Memory / In Honour of: ______________________________________________________________________________
Honouree Occasion: __________________________________________________________________________________
Next of Kin / Honouree info: ____________________________________________________________________________
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: _____________________ Province: ___________________ Postal Code: ___________________________________
Telephone: ____________________________ E-Mail:______________________________________________________
Next of Kin Relationship to Deceased: ____________________________________________________________________
Direct Donation To
Are you responding to a package received in the mail?
(Circle One)
Yes
No
Calgary Health Trust Annual Fund for Greatest Needs
Foothills Medical Centre:
Rockyview General Hospital:
Peter Lougheed Centre:
Greatest Needs
Greatest Needs
Greatest Needs
Staff Education
Staff Education
Staff Education
Unit / Program Greatest Needs:
Unit / Program Greatest Needs:
Unit / Program Greatest Needs:
_____________________________
______________________________
____________________________
Carewest:
Women’s Health:
Other
Greatest Needs
Greatest Needs
____________________________
Staff Education
Staff Education
Site/Program: ________________
Unit / Program Greatest Needs: ________________
Calgary Health Trust
800-11012 Macleod Trail SE Calgary, AB T2J 6A5
Phone: (403) 943-0615 Fax: (403) 943-0628
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Credit Card Information
Visa
MasterCard
American Express
Name on Credit Card: ______________________________________________________________________
Credit Card Number: _______________________________________ Expiry Date: ____________________
Signature: ________________________________________________
May 2009
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