Dedication Form - Wigan & Leigh Hospice

Details for the booking of Dedications

Important - Please enter the name of the person the dedication is BY and TO

Dedicated BY

Dedicated TO

Your details

Title*

First name*

Last name*

Address*

Address 1 * Address 2 Town * County * Postcode*

Telephone*

Email address*

Enter email* Confirm email*

Your Dedication

A daisy in our online daisy garden*

If you wish your dedication to appear as a daisy in our online daisy garden please select below. Please note - it is not compulsory to upload a photograph.

Yes, please show my daisy online
No, please don't

First name of person in dedication*

Last name of person in dedication*

Type their name as you would like it to appear on the dedication*

Memory Category

Your dedication message*

limited to 400 characters including spaces

Your dedication message

limited to 400 characters including spaces

Picture

maximum file size: 50MB
file types accepted: jpg, jpeg, png, gif

Image size: 182 x 182 pixels

Select Photo

Our wooden daisies*

As well as having a daisy dedicated to your loved one in our online daisy garden you may wish to have a beautiful wooden daisy dedicated to your loved one. This daisy will be engraved with the name of your loved one and planted in our memorial garden at the hospice. If you do not want us to plant a wooden daisy please click in the box below. (this helps to keep down our costs)

I want a wooden daisy
I do not want a wooden daisy

Collecting your daisy

If you would like a wooden daisy you may collect your daisy by prior arrangement with the fundraising team. Alternatively, you will be invited to attend a short dedication ceremony in Autumn when you can collect your daisy in person. Please click below if you would like to receive a letter with an invitation. Alternatively, please check our website for information nearer to the time. If you would like us to send your daisy to you in the post please contact the fundraising team on 01942 525566 or email: fundraising@wlh.org.uk. Please note that there will be a postage/administration charge of £3.50.

I would like to receive an invitation by post

Your Donation

We suggest a minimum of £10 donation

Your Donation*

Please enter amount*

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

Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is needed to identify you as a current tax payer

Gift Aid

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 want to Gift Aid my donations I make in the future or have made in the past 4 years

We would like to keep you up to date with the work we do here at the Hospice.

Hospice E-Newsletter

We will not share your information with other organisations.

Please notify us on 01942 525566 if you:

Want to cancel this declaration or Change your Name and/or Home Address
No longer pay sufficient tax on your income and/or capital gains.