Printable on line Donation and Dedication Form
Please fill in the form on line, and use your browser print function to print it out. Post it to us using ether of the addresses below depending whether or not you wish to use the freepost service	Note: you may freely use our FREEPOST address, however using the other address and affixing a stamp will save the Hospice administration charges
Harlington Hospice Association Lansdowne House St Peters Way Harlington Middlesex UB3 5AB	Harlington Hospice Association FREEPOST (SCE14380) HAYES UB3 5BR

I wish to make a donation in Memory of

Name

Who lived at

I enclose monies to the sum of:

(Please make cheques payable to the “HARLINGTON HOSPICE ASSOCIATION”)

Gift Aid increases the value of your donation by 28% without affecting your tax position.

If you are not a UK tax payer or do not wish for your donation to be included in the scheme

please write no here

Donation and dedication

From: -

Name

Address

Please

Include your

Postcode

Phone no

Email

I would also like you to send an additional letter acknowledging my donation in memory

to: -

(e.g.  to deceased’s spouse )

(Leave below blank if you do not require this service)

Name

Address

Please

Include

Postcode

Relationship

To myself

(e.g. farther, mother , aunty, close friend ,work colleague )

Expressing these

Thoughts

(Your message to the recipient e.g. I will miss him greatly, my thoughts are with you)

Reason

(Expression of sympathy, anniversary of death, donation in lieu of flowers) 

I do not do not do  want you to disclose the amount of money that I have donated