Donate In Memory Form

€

E-Mail *

Email Again *

Title *

First Name *

Surname *

Address Line 1 *

Please enter only letters (A-Z a-z) or numbers (0-9) Special Characters (:<>/%#&?',) cannot be processed

Address Line 2 *

Address Line 3

Town/City *

County *

Country *

Phone number (no spaces) *

Which fund would you like to donate to? *

Work of the Mercy

Would you like us to keep you updated about the fundraising appeals of the Mercy Hospital Foundation? 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 phone 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

You have ticked NO to all communications. If you would like to receive our annual Newsletter in the post please tick your choice below *

Yes, I am happy to receive only the annual Newsletter in the post

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

If you wish we can send a card to the bereaved family on your behalf. If you would like to send a card do you wish the amount donated to be written on the card? *

From: (If you wish to remain anonymous please leave blank)

In memory of

Who the card is to be sent to

Recipient's Address line 1