Donation Form

Welcome to the Monthly Giving Club!

Your thoughtful and ongoing donations go towards making an incredible difference in our community!

If you would prefer to have your monthly donation come directly from your bank account please contact us directly to set up automatic bank withdrawal. To arrange monthly credit card payments, please complete the form below.

[email protected] or 613-732-2811 ext 7408

Contact Information

Title

First Name

Last Name

Company Name

Address

City

Province

Postal Code

Home Phone

Cell Phone

Work Phone

Help Us Cover Costs

Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.

Yes! I want $0.00 to go to Pembroke Regional Hospital Foundation and I will donate $0.00 to cover the processing fees, totalling $0.00.No. I will donate $0.00 and Pembroke Regional Hospital Foundation will cover the processing costs.

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

Province

Postal Code

Country

Phone

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

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.