I would like to dedicate a
leaf on the Memory Tree
In return for my leaf I would like to support Pilgrims Hospices with a regular donation of
£__________________
Recommended monthly amounts per leaf:
Copper leaf: £10 per month
Gold:
£50 per month
Silver: £25 per month
Platinum Dove: £100 per month
Name and full postal address of your Bank or
Building Society
To: The Manager Service User Number:
Bank/Building Society
2 9 5 9 8 2
Reference Number (For office use only)
Address:
Instruction to your Bank or Building Society
Please pay Pilgrims Hospices in East Kent Direct Debits
from the account detailed in this Instruction subject to
the safeguards assured by the Direct Debit Guarantee. I
understand that this Instruction may remain with Pilgrims
Hospices in East Kent and, if so, details will be passed
electronically to my bank/building society.
Postcode:
Name(s) of Account Holder(s)
Signature(s)
Account number
Sort code
Please note your Direct
Debit will be taken on 1st
of each month
Date
OR In return for my leaf, please accept my gift to Pilgrims Hospices of £____________
Please find enclosed a cheque payable to Pilgrims Hospices in east Kent
Please debit my credit / debit card (Maestro, Visa or Mastercard)
Card holder’s name:
Card number:
Valid from:
3-digit security number:
Expiry date:
Issue number (Maestro only):
Signature(s):
Date:
Each year we will contact you to see if you’d like your leaf to remain on the Memory Tree for another year.
Please be aware it can take up to six weeks for the leaves to be engraved and placed on the Memory
Trees. We will be in touch to let you know when your leaf is on the Tree.
Increase the value of your gift by 25%
Please treat all donations I make now, in the future, or have made to
Pilgrims Hospices for the past 4 years as Gift Aid donations until further
notice. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in
the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility
to pay any difference. I understand that Pilgrims Hospices will reclaim 25p of tax on every £1
that I have given.
Signature(s):
Date:
Please turn over to write your dedication and fill in your details
Recommended annual amounts per leaf:
Copper leaf: £120
Gold leaf:
£600
Silver leaf: £300
Platinum dove: £1,200
Your Memory Tree
Your details
Name:
Surname:
Address:
Postcode:
Email:
Please provide us with an email address so we can send you an e-certificate to confirm the details of your leaf and dedication.
At this point you will be given 7 days to make any changes.
Please choose your leaf and hospice site:
Copper £10p/m Silver £25p/m Gold £50p/m Dove £100p/m One line, name-only dedication of 16 characters, including spaces
Two lines, name-only dedication of 18 characters per line, including spaces
Three lines dedication of 18 characters per line, including spaces
Three lines dedication of 18 characters per line, including spaces
I would like my leaf on the Memory Tree at:
Ashford
Canterbury
Thanet
In the boxes below please write the name/s of your dedication (please do not include dates)
If you would like to dedicate more than one leaf on the Memory Tree, please either photocopy this
form or call Supporter Relations on 01227 782 062 and they will send you another copy.
Pilgrims Hospices would like to keep you informed about
our work and how your support can help us to care for
people across east Kent. We promise that we will never
pass on your details. If you wish to adjust the frequency or
type of communications you receive from Pilgrims, you can
simply call us on 01227 782062 or email us at supporter.
[email protected]. Or, if you prefer to
never hear from Pilgrims again, tick here
Funds received will be used in accordance
with Pilgrims Hospices vision to ensure that
people with a terminal illness and their family
and friends are supported and empowered to
live well in mind and body until the very last
moment of their life.
Please return this form to:
FREEPOST RTJX-TKKU-ZJZU
Pilgrims Hospices
Plender House
56 London Road
Canterbury CT2 8JA.