Dedication form - Wigan & Leigh Hospice

Details for the book of Dedications

Important - Please enter the name of the person the dedication is BY and TO exactly as you would like it to appear in the book.

Dedicated BY*

Dedicated TO*

First name

Dedicated TO*

Surname

Your details

Title*

First name*

Last name*

Address*

Address 1 * Address 2 Town * County * Postcode*

This field is hidden when viewing the form

Telephone Number

Telephone

Email address*

Enter email* Confirm email*

Your Dedication

A star in our online night sky*

If you would like your dedication to appear as a star in our night sky please fill in the following. It is not compulsory to upload a photograph. Please try to use a square-shaped photograph. If you have any issues uploading your photograph please email: fundraising@wlh.org.uk Please fill in the details even if you do not want an online star so your dedication can be entered into our Book of Dedications

Yes, please show my star.
No, please don't show my star.

First name of person in dedication*

0 of 50 max characters

Last name of person in dedication*

0 of 50 max characters

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

This field is hidden when viewing the form

Memory Category

Your dedication message

limited to 400 characters including spaces

0 of 400 max characters

Your dedication message

limited to 400 characters including spaces

0 of 400 max characters

Picture

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

Image size: 182 x 182 pixels

Accepted file types: jpg, jpeg, png, gif.Select Photo

Your Donation

Your Donation*

Please enter your amount*

Billing Address*

Same as main address

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

This field is hidden when viewing the form

Shipping Address*

Same as main address

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

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 is a government scheme for UK charities to reclaim the tax you have paid and gain 25% more at no cost or hassle to you. I am a UK tax payer and I understand that if the Gift Aid claimed on my donation/s is more than the tax I pay in the current tax year (on my income and/or capital gains), it’s my responsibility to pay the difference.*

I wish Wigan & Leigh Hospice to claim Gift Aid on all donations I have made in the last four years and all donations I make from the date of this declaration until I notify you otherwise.
I want to Gift Aid this donation only
No, do not add Gift Aid

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.
Communications*
- I would like to receive information from Wigan & Leigh Hospice on the latest updates, events, e-newsletter and other information that may be of interest to me.
- No thanks
We will not share your information with other organisations.
Please select if you would like a thank you letter posted to you
Consent
I agree to the privacy policy.