Toronto General & Western Hospital Foundation Printable Donation Form

Please print, fill out and mail or fax this form. If you are donating on behalf of a company or an organization, please enter the company name and the appropriate contact information in the fields below.

Please note that we do not exchange, sell or rent any donor personal information to outside third parties.

Mailing address:

Toronto General & Western Hospital Foundation
R. Fraser Elliott Building
190 Elizabeth Street, 5th Floor
Toronto, On M5G 2C4

Fax: (416) 340-4864

Credit card donations can also be made by calling the Foundation at (416) 340-3935. We accept Visa, Mastercard and American Express.

*indicates a required field

Donor Information

Title:*

 __________

First Name:

 __________________________________________

Last Name:*

 ______________________________________________________

Company/
Organization:

 ______________________________________________________

Apt/Suite#:

 __________________

Address:*

 ______________________________________________________

City:*

 ______________________________________________________

Province/State:*

 __________________

Postal/Zip Code:*

 __________________

Country:*

 ______________________________________________________

Phone# (home):

 ______________________________________________________

Phone# (business):

 ______________________________________________________

Fax#:

 ______________________________________________________

Email Address:

 ______________________________________________________

 

 

Monthly Giving/ One Time Gift

Would you like to make your gift a monthly donation?

Yes, I want to join Toronto General & Western Hospital Foundation's monthly giving program. I authorize my monthly gift to be debited once a month.

No, thank you - please make this a one time gift.

Gift Amount:*
(circle one or fill in your desired amount)

$20 $35 $55 $100 $250
Other: $________________________

 

 

Currency Choice:*

CAD
USD

Payment Method:*
(circle one)
Visa Mastercard Amex Cash
Cheque
(make payable to "Toronto General & Western Hospital Foundation")

 
Credit card payment information: Card Number: __________________________________________
Expiry Date: ____ / ____
Signature: __________________________________________

 

I would like my gift to remain anonymous
I would like to be recognized as follows:

____________________________________

Choose a designation

Listed below are program areas where you may wish to direct your gift. We would also be pleased to discuss other options with you.

Please select one of the following:

 

To the area of greatest need
Advanced Practice Nursing
Asthma and Lung Disease
Cardiac Program
Diabetes
Emergency Department
Equipment
Eye Diseases and Vision Science
Family and Community Health Program (Healthy Connections)
Medical Imaging
Neuroscience
Musculoskeletal Disorders
Pain Management and Anaesthesia
Project 2008: Looking Forward, Living Life
Pulmonary Hypertension
Research Division
Surgical Program
Transplantation
Vascular Surgery and Medicine
Women's Health

Matching Gifts

Do you work for a matching gift employer?

Yes
No

If Yes, please provide us with your company name and main phone number:

______________________________________________
 

Commemorative Giving

If you wish to give your gift "in honour" or "in memory" of someone special please complete the following fields.

My gift is

in honour of
in memory of

Title:

 __________________

First Name:

 __________________________________

Last Name:

 ______________________________________________________
 

I would like an acknowledgement card to be sent to the following address:

Title:

 __________________

First Name:

 __________________________________

Last Name:

 ______________________________________________________

Apt/Suite#:

 __________________

Address:

 ______________________________________________________

City:

 ______________________________________________________

Province/State:

 __________________

Postal/Zip Code:

 __________________

Country:

 ______________________________________________

How would you like the acknowledgement to be signed?

 

__________________________________________________________

If you would like a special message to be added to the card, please provide it here:

 __________________________________________________________

 

Please send me information about the Toronto General and Toronto Western Hospitals. If you would like information on a specific topic, please provide details below.

 

 



Receipts will be issued for gifts of $20.00 or more to the extent allowed by law. For donations less than $20.00, receipts will be issued upon request.

Registered Canadian Charitable Organization Business Number:
12386 4068 RR0001