Please complete the short form below to share a memory of your loved one... "*" indicates required fields Your details... Title* Mr Mrs Miss Ms Dr First name* Surname* Email* Mobile number* Your address... 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Title of loved one in dedication* Mr Mrs Miss Ms Dr First name of loved one in dedication* Surname of loved one in dedication Please let us know their relationship to you Loved one's name as you would like it to appear Your dedication messageIf you wish to upload a photo of your loved one please do so hereFor best results please use landscape photos. Drop files here or Select files Max. file size: 5 MB, Max. files: 1. Your Donation... Did you know…? We are not the NHS. We are a charity and every year we need to raise £11 million of the £14.3 million we need to support the people of Coventry and Warwickshire. Could you help support The Myton Hospices to ensure we can continue to deliver our care free of charge? Your donation* £16 – could fund a patient’s meals for one day £28 – could fund an hour of specialist nursing care £150 – could fund a child to attend five bereavement counselling sessions £360 – could fund our Myton at Home service for one day £450 - could fund an inpatient bed for one day Other None Please enter the amount you wish to donate* I wish to Gift Aid my donation and increase its worth by 25% at no cost to me I am a UK tax payer and confirm I will pay an amount of UK income tax or Capital Gains tax for each year that is at least equal to the amount of Gift Aid that all charities that I donate to will reclaim on my behalf. I understand that if I pay less Income Tax/Capital Gains Tax in any tax year than the amount claimed on my donations, it will be my responsibility to pay any difference back.Giftaid* For the last four years /and any I may make in the future, until I notify you otherwise For my latest donation /and any I may make in the future, until I notify you otherwise I am NOT a UK taxpayer or do not wish to Gift Aid my donations Find out the difference your support makes Thank you for supporting The Myton Hospices so we can continue to provide our services free of charge to people, and their families, living with terminal illnesses. We may keep in touch with you by post and phone to tell you more about our vital work and other ways you can help, including opportunities to donate, fundraise or volunteer and how your support has made a difference. Please let us know if you’re also happy to hear from us by email and text: By email* Yes No By text* Yes No Your privacy We promise to do our best to keep your details safe and secure and will only process your data in accordance with the current Data Protection legislation. Our Privacy Policy explains how we keep this promise and you can read more online at www.mytonhospice.org/privacy-policy If you change your mind about hearing from us please email DSCT@mytonhospice.org or call us on 01926 358383. I have read and accept The Myton Hospices Terms and Conditions for this event* I accept I have read and accept The Myton Hospices Privacy Policy* I accept Total
