Tree of Memories

Your details

• First Name *
• Last Name *

• Address 1 *
• Address 2
• Address 3
• Town *
• County
• Country
• Postcode *

• Phone number
• Email *
  

  By providing your email address above you understand that we may email you in relation to this campaign. In order for us to communicate with you via email, your name and email address will be passed to a third party company who will act on our behalf. No other details will be passed on and your information will not be used to contact you for any other purpose. If you would prefer not to receive updates via email or change your mind in the future, please contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk. Please note that we may continue to contact you about this event via email in case of emergency.

Your Leaf

• Please select your chosen leaf colour or sunflower: Bronze (£100 donation. Leaf to remain on the tree for 1 year) Bronze (£250 donation. Leaf to remain on the tree for 3 years) Silver (£200 donation. Leaf to remain on the tree for 1 year) Silver (£525 donation. Leaf to remain on the tree for 3 years) Gold (£300 donation. Leaf to remain on the tree for 1 year) Gold (£800 donation. Leaf to remain on the tree for 3 years) Sunflower (£1,500 donation. Sunflower to remain on the tree for 3 years)

Your Inscription

Please engrave the following name or message on my leaf (please print clearly in capitals):

Inscriptions on a leaf or flower can consist of 15 characters per line, including spaces, up to a maximum of 4 lines

• Line 1:
• Line 2:
• Line 3:
• Line 4:

Would you like to Gift Aid your donation?

Boost your donation by 25p of Gift Aid for every £1 you donate.

Gift Aid is reclaimed by Kirkwood Hospice from the tax you pay for the current tax year. Your home address is needed to identify you as a current UK taxpayer.

In order to Gift Aid your donation you must tick the box below:

• I want to Gift Aid my donation and any donations I make in the future or have made in the past 4 years to Kirkwood 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.

Please notify us if you:

- want to cancel this declaration
- change your name or home address
- no longer pay sufficient tax on your income and/or capital gains

If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.

Declaration

• Accept Declaration
   Yes

Your communication preferences

We will use your address to administer your dedication, including sending your personalised card to you. We also send you our newsletter, information about Kirkwood Hospice and any other ways you can support our work, unless you tell us otherwise by contacting us on: 01484 557911 or fundraising@thekirkwood.org.uk