Please print this form, complete and fax it to: (416) 243-8523

Address: 82 Buttonwood Avenue, Toronto ON M6M 2J5 (416) 243-3698

Mr.__  Mrs.__  Miss__  Ms.__  Dr.__  Other___________

Last name:                                                          First name:

Receipt Address:
Company (if applicable): _________________________________________________________

Street: _______________________________________________________________________

Apt. ______ City______________________ Province__________ Postal Code__________

Telephone (_____) ______ - ________________ Email: ____________________________

I wish to make the following donation: $35__   $50__  $75__  $100__  Other $_________

All donations are tax deductible. Registered charitable business number: 11929 5350 RR0001

Payment type: Visa__ Mastercard__ Cheque__ (if mailing form)

Account #: ______________________________________________ Expiry ______________

Signature ________________________________________ Date ______________________

Please designate my gift
to one of the following services:
__ Long-term Care Service
__ Amputee Rehabilitation Service
__ Respiratory Rehabilitation Service
__ Neurological Rehabilitation Service
__ Multiple Sclerosis Service
__ Post Polio Clinic
__ Complex Continuing Care Services
__ ABI Behaviour Service

Other: _______________________________

In memory of:

_______________________________________

Please acknowledge: