Your Light Up A Life Donation… "*" indicates required fields Step 1 of 2 0% UNIQUE IDWill you be remembering a loved one at this year's Light up a Life?* Yes, I would like to dedicate in memory of a loved one No, I would prefer to make a donation without a dedication Your details... Title* Mr Mrs Miss Ms Dr First name*Last name*Email* Mobile number*Your address... Is your postal address based in the UK?* Yes, based in the UK No, not based in the UK Please enter your postcode and select your address*Address line 1*Address line 2Address line 3City / Town*CountyPostcode*Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsBilling State*Please select a stateALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISDTNTXUTVTVIVAWAWVWIWYPlease tell us where you heard about Light up a Life this year... Email Facebook Flyer Friends, family or word of mouth Instagram Letter Newspaper / Magazine Myton shop Myton's website Other website Poster Roadside banner Twitter Other Please tell us where*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 A dedication to someone special... First name*Last name*Their relationship to you*Do you wish to make another dedication Yes No First name*Last name*Their relationship to you*Do you wish to make another dedication Yes No First name*Last name*Their relationship to you*Do you wish to make another dedication Yes No First name*Last name*Their relationship to you*Do you wish to make another dedication Yes No First name*Last name*Their relationship to you*Do you wish to make another dedication Yes No We are sorry but we can only add five loved ones for each online form If you wish to remember more than five loved ones please call us on 01926 838830 or complete this form again (a link will be emailed to you and shown at the end of this form) Hospice you wish for your loved one's name displayed at* Coventry Myton Hospice – Sunday 7th December, 5pm Rugby Myton Support Hub – Friday 12th December, 7pm Warwick Myton Hospice – Sunday 14th December, 6pm Will you be attending one of our services* Yes No Please let us know which service you will be attending* Coventry Myton Hospice – Sunday 7th December, 5pm Rugby Myton Support Hub – Friday 12th December, 7pm Warwick Myton Hospice – Sunday 14th December, 6pm Roughly how many people will be attending including yourself* 0 1 2 3 4 5 6 7 8 9 10 10+ Will you be leaving an online tribute through our Memory Wall after this dedication? Yes No Unsure Donations of £40 or more will also receive a limited edition wooden photo frame... Please select an amount by clicking an image below... Your donation...* £40 – could cover the cost of one hour’s specialist nursing care £79 could fund a child to attend a bereavement counselling session £360 could fund our Myton at Home service for a patient for one day £450 will fund an Inpatient bed for one day £1,486 could fund the cost of our Rugby Myton Support Hub for one week Other Other*Donations of £40 or more will also receive a limited edition wooden photo frame... Would you like a limited edition wooden photo frame?* Yes please No, thank you I wish to Gift Aid my donation and increase its worth by 25% at no cost to me... I am a UK taxpayer and would like The Myton Hospices to treat this donation, any donations I make in the future, and any I have made in the past four years, as Gift Aid donations until I notify you otherwise. I 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 select one* Yes, I want to add Gift Aid No, I am NOT a UK taxpayer or do not wish to Gift Aid my donations This field is hidden when viewing the formGA Date Four YearsThis field is hidden when viewing the formGA Date today DD slash MM slash YYYY This field is hidden when viewing the formGA No Date DD slash MM slash YYYY Leave a Lasting Legacy... Did you know that 1 in 4 of our patients are cared for by Gifts in Wills? You don’t have to be wealthy to make a difference to people’s lives; large or small, a gift from you can help our patients and their families at a time when they need us the most. By including a gift in your Will for Myton you will be supporting your local charity, making a positive difference for your community and leaving a lasting legacy.Gift in Wills Post me a free Gifts in Wills pack Event Registrations T&C's... Contact details provided (including email address and telephone number) are used to keep you up to date about the event you are taking part in and support you in your fundraising efforts. Where appropriate we may ask for next of kin details in case of an emergency. All details will be stored securely and are used in relation to the event you are taking part in. Please ensure that you read a full copy of our terms and conditions for this event by clicking here. 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. We will only communicate with you in the way(s) that you have agreed to. If you change your mind about hearing from us, contact us at any time by emailing our Donor & Supporter Care Team at DSC@mytonhospice.org or calling 01926 358 383. For further details on how your data is stored visit: https://www.mytonhospice.org/privacy-policy/ I agree to The Myton Hospices events Terms and Conditions* I agree I agree to The Myton Hospices Privacy Policy* I agree Total Review Your Debit / Credit Card Details... Please complete these as they are detailed on your Debit / Credit card that you wish to pay with. Failing to do so may result in a failed payment. You will then be transferred to a secure payment page to complete your card details.First name as detailed on Debit/Credit card*Last name as detailed on Debit/Credit card*Address line 1 registered for Debit/Credit card*Address line 2 registered for Debit/Credit cardCity / Town registered for Debit/Credit card*Postcode registered for Debit/Credit card*Country registered for Debit/Credit card*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweBilling State registered for Debit/Credit card*Please select a stateALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISDTNTXUTVTVIVAWAWVWIWYYou have entered a donation less than £1, please return back to the donation process and enter a donation of £1 or more to complete your dedication. 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