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Gifts of Kindness Order Form

$35 - Treats

"We all scream for ice cream! Thanks to a gift made in your name, seniors living in a Victoria, BC long-term care home will receive a special ice cream treat!"

$ 35.00

Quantity:

$40 - Gardening

"A love of gardening is always in season. Thanks to a gift made in your name, plants and gardening supplies will be provided to a long-term care home or adult day program in Victoria, BC."

$ 40.00

Quantity:

$50 - Music

"Music soothes the soul. Thanks to a gift made in your name, a senior living in a Victoria, BC, long-term care home will experience the joy of music therapy."

$ 50.00

Quantity:

$75 - Wheels

"Wheels mean freedom at any age. Thanks to a gift made in your name, a senior living in a Victoria, BC long-term care home will feel the freedom of movement!"

$ 75.00

Quantity:

$100 - Movement

"The joy of movement. Thanks to a gift made in your name, a senior living in a Victoria, BC long-term care home will have access to specialized therapy equipment to help maintain their health, strength, and mobility."

$ 100.00

Quantity:

Quantity

Total owed: CA$

Name*

First Name

Last Name

Phone*

Mailing Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Credit Card Number*

I wish my donation to remain anonymous (you will still receive a tax receipt)

Is your billing address the same as your mailing address?*

Yes No

Billing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Where would you like the card(s) to be sent?*

I would like them mailed to me I would like them to be mailed to someone else

Recipient 1

Which Card is this for?*

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 2

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 3

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 4

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 5

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 6

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 7

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 8

Which Card is this for?*

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 9

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Recipient 10

Which Card is this for? *

Gardening Treats Wheels Music Movement

Recipients Name

First Name

Last Name

Recipients Mailing Address

Address Line 1

Address Line 2

City

Province

Postal Code

Personal Message:

Gifts of Kindness Order Form

Recipient 1

Recipient 2

Recipient 3

Recipient 4

Recipient 5

Recipient 6

Recipient 7

Recipient 8

Recipient 9

Recipient 10

For More than 10 recipients please email (tania.fritz@islandhealth.ca) or phone us 250-370-5664