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Is this gift is in memory or in honour of someone?*
  • In Memory
  • In Honour
This gift is in memory or in honour of (Enter full name): *
Gift Notification*
  • Please notify the following person of my gift*
  • Thank you, no notification required
*First & Last Name:
Mailing Address:
Gift Message:

Gift Information

I would like to donate to:*
  • Cancer
  • Public Health
  • Pediatrics & Obstetrics
  • Mental Health
  • Clinical Nursing/Administration
  • Occupational Health
  • Research
  • Use as needed
  • Operations Fund
Donation Amount*
  • $25 CAD
  • $50 CAD
  • $100 CAD
  • $300 CAD
  • $500 CAD
  • Other $

Contact Information

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State / Province*
Address*
City*
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I would like my gift to be recognized as*
  • In my own name
  • Other*
  • Anonymously
*If Other, enter recognition name here:

Payment Information

Amount*
$
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