Southlake Regional Health Centre Foundation

Thank you for your generous monthly gift!

Your ongoing commitment to Southlake will help ensure that your family, friends and neighbours have access to leading-edge care, close to home.

Please complete the form below to initiate your monthly, tax-deductible donation now.

Are you looking to make a corporate donation? If so, click here.

If you have any questions about your gift, please contact Southlake Foundation at 905-836-7333 or foundation@southlakeregional.org.

Corporate Donation

Field Is Required Select Gift Amount:

$100.00

$100

$50.00

$50

$25.00

$25

$15.00

$15

Enter amount

Field Is Required Gift Designation:

Use my gift where it is needed most.

Direct my gift to:

Where would you like to designate your gift to?

*Please Note: If you selected ‘other’ rather than one of the Hospital’s identified priorities we may need to contact you to ensure that your donation can be put to work as quickly as possible in the area of the hospital you wish to support.

Donor/Receipt Information

Title:

First Name:

Last Name:

Street 1:

City:

State/Province:

ZIP/Postal Code:

Country:

Preferred Phone Number:

Email Address:

Yes, I would like to make this donation anonymously.

Yes, I would like to receive occasional email updates from Southlake Regional Health Centre Foundation. To opt-out of receiving these communications, please uncheck the box.

I am proud to be part of the Southlake Family as a physician, staff or volunteer

I am proud to be part of the Southlake Family as a physician, staff or volunteer.

Payment Information

Credit Card Information:

Credit Card Type:

Credit Card Number:

Expiration Date:Select month of credit card Select Expiration Year

CVV Number: What is this?

102-581 Davis Dr
Newmarket, Ontario
Canada L3Y 2P6

905.836.7333 | 1.877.457.2036

foundation@southlakeregional.org

www.southlakefoundation.ca

Southlake Regional Health Centre Foundation respects the privacy of our donors and does not sell or trade any donor information.

For more information, please visit the Privacy Policy & Terms of Use

Charitable Registration Number: 13179 7540 RR0001