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Donation Form
I would like to make a donation of:
Amount
$500 A nurse consultation for 5 people
$250 Speech Maintenance Class for 20 people
$150 A physio consultation
$100 A nurse consultation
$50 Peer-to-peer support group facilitation
Other amount
$
$500 A nurse consultation for 5 people
$250 Speech Maintenance Class for 20 people
$150 A physio consultation
$100 A nurse consultation
$50 Peer-to-peer support group facilitation
Other
$
Total amount
$
Pay/Donate method
*
Credit Card
Direct Credit
Make deposit to account
02-1257-0062965-000
Pay processing fee
$
Message with your donation:
Billing Details
Persons name
First name
Last name
Persons address
Address line 1
Address line 2
Town/Suburb
City
Postcode/Zip
Organisation name
if applicable
Email address
Cell phone
Home phone
THANK YOU FOR YOUR SUPPORT
MS and Parkinson’s Canterbury Charitable Trust
3/49 Sir William Pickering Drive
Burnside, Christchurch 8053
www.ms-pd.org.nz
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