DONOR INFORMATIONName* First Name Last Name Company Name Company Name Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryCanadaUnited States Country Telephone*Email* TYPE OF GIFTPlease select the type of gift you would like to make with your donation:*Area of greatest needSpecific Fund, Department or Community EventSpecify which Fund, Department or Community Event:*TYPE OF DONATIONPlease select the type of General Donation you would like to make:*A single one time donationMonthly donations (credit card or debit pre-authorized payments) PAYMENT METHOD - Single DonationPAYMENT METHOD - Monthly DonationI would like to make a donation in the amount of:*$1000$500$250$100$50OtherSingle Donation Amount Price: $ 1,000.00 CAD Single Donation Amount Price: $ 500.00 CAD Single Donation Amount Price: $ 250.00 CAD Single Donation Amount Price: $ 100.00 CAD Single Donation Amount Price: $ 50.00 CAD I would like to make a monthly donation in the amount of:*$20$15$10OtherMontly Donation Amount Price: $ 20.00 CAD Monthly Donation Amount Price: $ 15.00 CAD Monthly Donation Amount Price: $ 10.00 CAD Enter your Donation:* Payable on the 1st day of each month. If the 1st is a Saturday, Sunday or statutory holiday, your donation will be processed on the following business day. A receipt for income tax purposes will be mailed to you at the beginning of the next calendar year. You may modify or discontinue your monthly donations at any time. Please inform us by phone at 514-630-2081 at least seven (7) business days before the scheduled date of your next gift, so that we can ensure that no additional donation is processed.PAYMENT METHOD - Monthly DonationPAYMENT METHOD - Single DonationWould you like a tax receipt?*(Please note that for amounts under $25, receipts are sent upon request )YesNoPlease select your preferred method of payment:*Direct DebitCredit CardDirect Debit WithdrawalName of financial institution*Account number*Transit number*Or write a cheque to the Foundation with VOID written on it The Lakeshore General Hospital Foundation 160 ave. Stillview, suite 1249 Pointe-Claire, Québec H9R 2Y2Credit Card PaymentBilling Information* Same address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryCanadaUnited States Country Credit Card Information* American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Summary**Please confirm that all information is correct.** Name: {Name (First):1.3} {Name (Last):1.6} Company Name: {Company Name (First):87.3} Address: {Address (Street Address):2.1}, {Address (City):2.3} {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Telephone: {Telephone:3} Email: {Email:4} Type of gift: {Please select the type of gift you would like to make with your donation::16} Donation purpose (if specified): {Specify which Fund, Department or Community Event::17} {Please select the type of General Donation you would like to make::12} Donation amount: {I would like to make a donation in the amount of::38} {I would like to make a monthly donation in the amount of::72} {Enter your Donation::44} Total $ 0.00 CAD Share your StoryShould your generosity be a testament of your hospital experience, or that of a loved-one, and if you care to share your story, please feel free to contact us, as we cherish your feedback.Share your story:CaptchaPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
