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LAQ Donation Form

LAQ Donation Form


The LAQ is a registered charitable organization dedicated to raising awareness about lymphedema and providing support and education to people living with lymphedema. The LAQ depends on its membership fees and on donations to achieve its objectives. The LAQ welcomes donations at all levels. Charitable donation receipts will be issued for amounts over $10. (Registered Charity Number 868288978 RR0001)

Please fill out this form, print it from your browser and mail it together with your
cheque or credit card information made out to the LAQ at:

Lymphedema Association of Quebec
6565 St. Hubert, Montréal, QC H2S 2M5

Note: ** indicates mandatory field

Please accept my donation as follows:

 1. My Contact Information
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 **Last Name:
 **First Name:
 **Address:
 **City:
 **Province / State:
**Postal Code / Zip:
 **Daytime Phone Number:.
 Evening Phone Number:
 Fax Number:
**Email Address:

 2. Honoree Information (Optional)
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This is a gift:  
in honor of.
  in memory of.
Name of Honoree:
(required)
 Address:
 City:
 Province / State:
Postal Code / Zip:
Choose One:
Please send a tribute letter to my honoree.
  Please do not send a tribute letter to my honoree.
Optional Comment:
If you wish, you may indicate the occasion and/or include a brief statement about this person/your donation. Your text will be included in the note we send to your honoree to alert them of your donation (if you request that a letter be sent).
Choose All That Apply:
 Please send me a copy of the tribute letter.
  Please include the donation amount in the tribute letter.
   

 3. Amount of Donation
-----------------------------------------------------------------------------------------

Please indicate the LEVEL of today's gift:
 $10.00
$25.00
$50.00
$100.00
$101-500
$501-1,000
$1,001-5,000
Silver Supporter: $5,001-25,000
Gold Supporter: $25,000+
Other
**Amount of My Donation:
 $
 4. Method of Payment**
(When mailing, Please print this page completed and send with your donation to the address below)
-----------------------------------------------------------------------------------------
Check donation (fill in this form and mail to LAQ with check enclosed)
Credit Card donation (Print out this form completed with Credit card information and mail to LAQ)
FOR CREDIT CARD PAYMENTS : If paying by credit card, please print this document then fill in the credit card information below and mail to LAQ.
Name on Card :  
Credit Card Type :  
Visa Mastercard
Credit Card Number :  
 (to be filled in after printing)
Expiration date :  
/
 
 
 
Thank you for your generous donation.

LAQ Mailing Address
Lymphedema Association of Quebec
6565 St. Hubert, Montréal, QC H2S 2M5

Tél : 514-979-2463

aql@infolympho.ca

DISCLAIMER: This site is for information and community support only, and should not be used as a substitute for professional medical care. Always seek the advice of your physician with any question about a health problem or medical condition. This site also includes links to websites providing information about lymphedema, but the LAQ cannot be responsible for the content of those sites.
Copyright © 2008 Infolympho, all rights reserved.