Monthly Donation Form

Name*
First Last
Address*
Street Address Address Line 2 City County / State / Region Eircode Country
Email*
Phone
Message For Your Leaf*
Bronze Leaf Quantity
Price: € 8.50
Please note this is paid monthly.
Silver Leaf Quantity
Price: € 12.50
Please note this is paid monthly.
Gold Leaf Quantity
Price: € 21.00
Please note this is paid monthly.
Total
€ 0.00
Please note this is the total you pay monthly.
Method of Payment*
Card Details
Cardholder Name
Please check the box below to proceed.*
- I confirm I wish to set up a Recurring payment
Keeping in Touch
We may need to contact you regarding event administration and any communications relating to the Weekly Draw.
Please indicate your preferred method for us to contact you.
- Post
- Phone
- Email
- SMS
We would love to keep you updated about Galway Hospice services, fundraising initiatives, hospice news and let you know how your support has helped us continue providing our services.
Tick below if you do not wish to receive any future communications from us.
- I do not wish to receive any future communications from Galway Hospice.
Phone
This field is for validation purposes and should be left unchanged.

Keeping in Touch