Dedication Form - Eden Valley Hospice

Step 1: Create Your Memory Tree Leaf

Dedication(Required)

Please enter the exact name or message you’d like engraved. You have up to 26 characters, including spaces. (We’ll engrave it exactly as written, so please double-check spelling.)

Please let us know your relationship to the person you are dedicating your leaf to?

(e.g., Mum, Friend, Colleague)

Step 2: Choose Your Leaf Colour

Please choose your leaf colour:(Required)

Gold

White Gold

Rose Gold

Step 3: Your Details

Full Name(Required)

Title First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

How did you hear about Your Memory Tree?

Please tick below if you would like to hear from us via email (select the categories you wish to hear about):

Hospice news

How to support the hospice

Lottery/raffle updates

You can update your preferences or withdraw your consent at any time by contacting communications@edenvalleyhospice.org or calling 01228 810801. Our Privacy Policy can be found on our website at www.edenvalleyhospice.org/privacy-policy

Step 4: Choose Your Donation

You can make a single donation or pay monthly via direct debit.

How would you like to donate?

One-off donation

Suggested minimum donation of £150.

Please enter your donation amount

Monthly donation (Direct Debit)

Suggested minimum donation of £12 per month, for a minimum of 12 months.

How much would you like to donate each month?

Start date of the Direct Debit

Duration of Direct Debit

Direct Debit Agreement

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.

• If there are any changes to the amount, date or frequency of your Direct Debit Eden Valley Hospice will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Eden Valley Hospice to collect a payment, confirmation of the amount and date will be given to you at the time of the request.

• If an error is made in the payment of your Direct Debit, by Eden Valley Hospice or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society.

• If you receive a refund you are not entitled to, you must pay it back when Eden Valley Hospice asks you to.

• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

Gift Aid

Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is needed to identify you as a current UK taxpayer.

Tax Status

I am a UK taxpayer and I confirm the donation I make today is my own money and not part of a collection or a business donation, and I understand that if I pay less Income and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.

Please notify Eden Valley Hospice & Jigsaw if you:

Want to cancel this declaration
Change your name or home address
No longer pay sufficient tax on your income and/or capital gains

Would you like to Gift Aid your donation?

I want to Gift Aid this donation and any donations I make in the future or have made in the past 4 years to Eden Valley Hospice and Jigsaw.

Payment details

Dedication Form – Your Memory Tree