DonorType:

 
 

Title:

 
 

First Name:

*

  
 

Middle Initial:

  

  
 

Last Name:

*

  
 

Email Type:

  
 

Email:

*

  
 

Organization Name:

 
 

Adress Type:

  
 

Country:

*

  
 

Address:

*

  
   

 
 

City/Town:

*

  
 

Province/State:

*

  
 

Postal Code:

*

  
 

Phone Type:

  
 

Telephone:

   Ext:    *

  
       
 

   If you do not wish to receive further e-mail communication from us, please click this box.
       
       
 

   If you prefer to hear from us via regular mail, once per year, please click this box.
       
 

   If you do not wish to receive any communications (via print, phone or e-mail), please click this box.
       
 

Please indicate the preferred timing of your mail:    Winter   Fall
       
 

I would like to receive my correspondence in :    English   French
   
 

I wish to remain anonymous
       
 

I would like to make a donation of :
  $35 $500  
  $50 $1,000  
  $100 $2,500  
  $250 $5,000  
    Other:  $   
       
 

I want to make a gift through the Tribute Program
  In Memoriam    
  In Honorarium    
   
 

Please designate this gift to:
   Priority Needs
   Other:
   
 

Payment method:
             
   
  Cardholder's name:
  Card number:
  Expiry date:  /   (MM/YY)
   
 

Comments:
 
 
   
 

I would like more information on:
   The Governors' Circle.
   Bequests, Life Insurance, Gifts of listed securities.
   The In Memoriam Tribute Program.
   The In Honorarium Tribute Program.
   Gifts from Foundations, Associations and Corporations.
   The Friends of the Vic Monthly Giving Program.
   The Friends of the Vic Monthly Giving Program.

  The Royal Victoria Hospital Foundation is committed to protecting the privacy of the personal information of its constituents (employees, donors and other stakeholders). We value all of our supporters and are committed to working with each for their benefit and that of the Hospital.
We do not trade, rent or sell the names of our valued supporters.