Donation Form

Give The Gift of Mobility

Donations go directly to changing a life today!

How much would you like to donate? Each CAD $195 provides a wheelchair. A minimum of CAD $35.00 is required for Canadian tax receipt purposes.

$ Donation Amount:

Who's giving today?

We’ll never share this information with anyone.

Personal Info

First Name *

Last Name

Is this donation on behalf of a company?

No
Yes

Company Name

Email Address *

Make this an anonymous donation.

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Donation Information

Please provide information about the donation

Campaign

Comments (Please provide other details here including Council No. / Club Name etc. if applicable)

Presentation Folder Information

Your $195 donation will allow us to deliver a brand new wheelchair into the life of a person in desperate need of mobility. For each $195 donation, you will receive a beautiful presentation folder with the picture of a wheelchair recipient inside. Click the image below to view a larger photo of the presentation folder.

Please indicate if you wish to receive a presentation folder (Please note this only applies to gifts of $195 or more). If you are not requesting a folder, enter "No thank you", and then skip to the credit card information section of this form below.

Please send me a presentation folder

Credit Card Information

We accept MasterCard, Visa, and American Express

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

Province *

Zip / Postal Code *

Here's what you're about to donate:

Donation Summary
Payment Amount
Giving Frequency	One time
Donation Total

Donation Total: $195