Christmas appeal one off donation form

One off donation

How much would you like to donate?*

£25 could pay to provide specialist clinical support to ensure a patient’s pain is under control and they’re comfortable for the night ahead.
£150 could pay for a registered nurse’s shift, enabling them to care for the patients at the hospice.
An extraordinary gift of £887, would cover the cost of a bed at the hospice for a whole day.
Other

Other amount*

Donation Total

£ 0.00

We will send you a confirmation of this donation via email.

I want to Gift Aid my donation and any donations I make in the future or have made in the past 4 years to Prospect Hospice. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. I understand that Prospect Hospice will reclaim 25p of tax on every £1 that I have given

Title*

First Name*

Last Name*

Address Line 1*

Address Line 2

Town / City*

County*

Post Code*

Phone Number*

Email Address*

Please let us know how you would like us to use the email address you have provided*

Please use my email address to update me about all Prospect Hospice news, events and activities in the future
Please use my email address to only update me about this activity or event in the future
I do not wish to be contacted via email

Please let us know how you would like us to use the phone number you have provided*

Please use my telephone number to update me about all Prospect news, events and activities in the future
Please use my telephone number to only update me about this activity and event in the future
I do not wish to be contacted via telephone

Once you complete this form, you will be directed to our secure payment provider to take your payment.

Name

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