Brick/Paver Form

For parents, grandparents, aunts, uncles and friends who wish to celebrate the lives of babies born at the Perth and Smiths Falls District Hospital. All funds support ongoing projects and programs for Women's Health Initiatives.

Star Information

Amount

Please enter the FIRST NAME, LAST NAME and BIRTH YEAR

Star One

Star Two

Star Three

Star Four

Star Five

**Please ensure that all information is correct. There will be a $25 cost to reprint any misspelled star based on information provided**

Contact Information

First Name

Last Name

Address

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

Province

Postal Code

Privacy Policy
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Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.