LDMH Hospital Foundation The Foundation exists to financially support the acquisition of medical equipment and the expansion of facilities at Leamington District Memorial Hospital. Through active solicitation and recognition of donations, the Foundation serves as a conduit of community support, linking donors and the general public with the Hospital. The Foundation’s Board of Directors are comprised of both community representatives and active Hospital Board Trustees.
~ YOU CAN MAKE THE DIFFERENCE ~
Complete this form and mail your donation in support of Leamington District Memorial Hospital.
DONOR INFORMATION Name:______________________________________________ Address:_______________________________________________________________ Town/City:________________________________ Postal Code:_______________
Phone:___________________________
Date:__________________________________ Memorial Tribute: In Memory of:_________________________________
$20 $50 $100 $200 $500 $1,000 Other Amount:_________
Cheques payable to: Leamington District Memorial Hospital Foundation 194 Talbot Street West Leamington, ON N8H 1N9 Ph: 519-326-2373 (4143) • Fax: 519-322-5584 CREDIT CARD INFORMATION:
Visa
MasterCard
Card Number:________________________________________Expiry_______ Date:_____________ Signature:__________________________________________________ An income tax receipt will be issued promptly for donation of $10.00 or more. Charitable Registration #14064 7116 RR0001
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