Thank you for donating to The Wesley Hospital

Thank you for agreeing to make a donation to The Wesley Hospital. We are very grateful. Completing your donation will take just a few minutes and a receipt will be sent to you via email.

1. How much do you wish to donate?

	$25.00 AUD
	$50.00 AUD
	$100.00 AUD
	$200.00 AUD

Specify amount:

(For example, to donate $100.00 AUD just type in 100 or $5.50 AUD type in 5.5. No symbols or words please.)

2. Donor Details

Your personal and contact details for our records.

I am donating as

an individual.

a company or organisation.

Company or Organisation Name:

Personal Details

Salutation:

First Name

Last Name

Contact

Email Address

Confirm Email

Phone

Address

Country

Street 1

Street 2

Suburb

State

Postal Code

3. Further communications

Keep in touch.

Please check the box if you wish to receive more info from The Wesley Hospital

I would Like Everyday Hero to send me a copy of the receipt at the end of the financial year.

4. Payment Method

How would you like to pay?

Pay with Credit Card Visa_37x23 Master_37x23

Cash or Cheque Bpay_23 Austpost_23