Wall of Gratitude Request Form

To begin the process of ordering your butterfly, please fill in the details below. A member of our team will then be in touch with you with more details on how to proceed before your order is complete. Note this form will not take any payment for the butterfly.

Title *

First Name *

Surname *

Email *

Email Again *

Address Line 1 *

Address Line 2

Address Line 3

Town/City *

County *

Country *

The name of the person you would like on the butterfly *

Any further details you would like to give about your butterfly order? *

Phone *

Eg. +353 87 1234567 or +353 21 7654321

Work of the Mercy

Would you like us to keep you updated about the fundraising appeals of the Mercy? Tick or untick the boxes as you wish.

I'd like to be updated by post *

(we have just two mail campaigns a year)

Yes

I'd like to be updated by phone *

(we will never ring you more than three times a year)

Yes

I'd like to be updated by e-mail *

(we can send you our monthly e-zine with updates, stories and more)

Yes

If you would like to receive our bi-annual newsletter in the post from The Mercy Foundation please tick your choice below *

Yes I am happy to receive the newsletter

No, I do not want to receive any communications at all from The Mercy Hospital Foundation

Wall of Gratitude Request Form

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