Your donation Please select One-off donation if you're paying in money from sponsorship or fundraising. One-off donation Regular donation Please choose your amount: * £20 £50 £100 £3 £5 £10 Or surprise us £ Donation - both * I am making a donation on behalf of a company, group or association Company donation My in memory donation My donation is in memory of Short message Gift Aid Choose to Gift Aid and increase your donation to £0.00 at no extra cost to you. I want to Gift Aid my donation and any donations I make in the future or have made in the past four years to Children’s Hospice South West. I want to Gift Aid my donation and any donations I make in the future or have made in the past four years to Children’s Hospice South West. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. What is Gift Aid? Please notify the charity if you want to cancel this declaration, change your name or home address or no longer pay sufficient tax on your income and/or capital gains My contact/billing details Email * Daytime tel * Company name Name and Address * Title * - Select -MrMrsMsMissDrProfRev First name * Last name * Postcode * Find my address Address line 1 * Address line 2 Address line 3 Town/City * County * Country * United KingdomAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Payment details Your monthly donation will be collected on the 16th of every month. Please note that if 16th falls within 18 days of completing this form your first donation will be collected the following month. Account holder's name * Account number Sort code Instructions to your Bank or Building Society Please pay Children’s Hospice South West (CHSW) Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with CHSW and, if so, details will be passed electronically to my Bank or Building Society. Banks and Building Societies may not accept Direct Debit Instructions for some types of account. View the Direct Debit Guarantee By clicking 'Donate Now' you are confirming that you are the account holder and that you are the only person required to authorise debits from this account. Your contact preferences Children’s Hospice South West would like to keep you updated with news about our hospices, fundraising activities and campaigns and other ways you can help make a difference to short and precious lives. Please let us know below how you would like us to contact you. If you change your mind in the future, you can opt out at any time. I confirm I am over 18: * Yes No Please confirm if you are happy for us to contact you by: post: Yes No phone: Yes No email: Yes No Contact preferences Your privacy We take your privacy seriously. We will store your details securely on our database(s) and we will only use your personal information to provide the services you have requested from us. We will never share your details with third parties for marketing purposes without your prior explicit consent. For more information, please see our Privacy Policy or call 01271 325 270. Leave this field blank Total £0.00Donate Secure payment
