Urgent Care Appeal Donation Form

1) Personal Details

Title

Name *

First

Last

Address *

Address Line 2

Town/City *

County

Postcode *

Country

Phone

Email *

2) Your Donation

Please choose your gift:

£28.65, which would pay for three nutritious meals a week for one patient and their carer living at home
£50.15, which could pay for two hours of compassionate, expert care in the Hospice
£75.90, to cover the cost of three online bereavement counselling sessions for someone grieving the loss of a loved one
£150, to enable four weeks’ worth of online meetings/groups between a patient at home and one of our Hospice team
£2,440, because I’d like to replace one full day of St Andrew’s lost income
Your own preferred gift amount

Your gift: *

Please enter your own preferred gift amount

Gift Aid: *

Yes
No

I confirm I authorise St Andrew's Hospice to treat all donations I have made for the four years prior to this / today / any future donations until I notify you otherwise as gift aid donations. I confirm I have paid or will pay an amount of UK income tax and/or capital gains tax for each tax year 6th April to 5th April that is at least equal to the amount of tax that all the charities or CASC that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and council tax do not qualify. I understand the charity will reclaim 25p on every £1 that I give. What is Gift Aid?

3) Payment

Total

£ 0.00

Payment Card Details *

Card

Name on Card

Please tick this box if you DO NOT require a written acknowledgement of this gift posted out to you.

Mailing Preferences

Please select the ways we can keep in touch with you: *

We really value your support and would like to stay in touch to keep you up to date on the work of St Andrew's Hospice including our events and fundraising activity. We will never sell or share information with other charities or organisations for marketing purposes not related to St Andrew's Hospice.